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COEXRIGHT DEPOSIT. 



COMMON DISEASES OF THE SKIN 



WITH NOTES ON 



DIAGNOSIS AND TREATMENT 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO - DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



COMMON DISEASES 
OF THE SKIN 



WITH NOTES ON 



DIAGNOSIS AND TREATMENT 



BY 



G. GORDON CAMPBELL 

w 
B.Sc, M.D., CM. 

LECTURER ON DERMATOLOGY AND PEDIATRICS 

MCGILL UNIVERSITY ; PHYSICIAN TO THE 

MONTREAL GENERAL HOSPITAL 



THE MACMILLAN COMPANY 

1920 

Ah rights reserved 






Copyright, 1920, 
By the MACMILLAN COMPANY. 



Printed from type. Published February, 1920 



FEB 25 1920 . 



J. S. Cushing Co. — Berwick & Smith Go. 
Xorwood, Mass., U.S.A. 



©CI.A559808 



/ 



PREFACE 

The object of this small volume is to provide illustrations 
and a short description of some of the commoner diseases of the 
skin, with a few lines on differential diagnosis and methods of 
treatment. Xo one appreciates better than the author that 
dermatology can only be properly taught from clinical material, 
but this is not always within reach of the student and illustra- 
tions can in a measure replace it. The book is not intended 
to take the place of the larger works on dermatology, but 
the necessarily comprehensive nature of such works makes 
them at times a source of confusion to the student, whose 
lack of knowledge renders it difhcult for him to identify one 
disease among the descriptions of a number of somewhat 
similar, but perhaps rare, ones. Graduates of the Faculty of 
Medicine of McGill University wdll recognize that the views 
enunciated closely follow the teaching of the former Professor 
of Dermatology, Dr. Francis J. Shepherd, whose almost uncanny 
astuteness in diagnosis and simple methods of treatment the 
writer had the advantage of folloAving for twenty years as his 
assistant in the Montreal General Hospital clinic. In choosing 
the diseases which should be included in a work of this scope, the 
writer has based his selection on the statistics of the hospital 
chnic with which he is connected, thereby, possibly, admitting 
some not properly classed as common, because of the large 
proportion of aliens in his clientele. 

^Montreal, 123 Crescent Street 



CONTENTS 



Preface . 

Contents . 

Acne Comedo . 

Alopecia . 

Alopecia Areata 

Carcinoma . 

Chloasma . 

Dermatitis ;Medicamextosa 

Dermatitis Repexs . 

Dermatitis \'exexata 

Eczema 

Eczema Seborrhoicum 

Erythema ^Iultiforme 

Erythema Nodosum . 

Favus 

furunculus 

Herpes Simplex 

Herpes Zoster . 

Ichthyosis . 

Impetigo Coxtagiosa 

Keloid 

Keratosis Pilaris . 

Lichen Planus . 

Lltus Erythematosus 

^Miliaria . 

^Miliaria Crystallixa 

^Milium 

N.^vus 

Pediculosis 

Pityriasis Rosea 



viii CONTENTS 



PAGE 



pruritus 141 

Psoriasis 142 

Purpura 157 

Ringworm 163 

Scabies 174 

Seborrhcea 178 

Sycosis Vulgaris 179 

Syphilis 181 

Tinea Versicolor 209 

Tuberculosis 212 

Urticaria 219 

Verruca 224 

Vitiligo 228 



COMMON DISEASES OF 
THE SKIN 



ACNE COMEDO 

Acne and Comedo are disorders of the sebaceous glands 
closely related to each other and for that reason considered to- 
gether. A Comedo is the plugged duct of a sebaceous gland, due 
either to the secretion of the gland having become too thick to 
escape freely, or to an occlusion of the orifice of the gland having 
dammed back the sebum which, together with epithehal cells, 
collects in the duct. The lumen of such a duct becomes dis- 
tended, and in the course of time, dust collecting in its mouth, 
gives rise to a dark point commonly known as a '' blackhead." 
Pressure on the skin about the opening of the duct will express its 
contents of thickened sebaceous material in a long, cyhndrical 
worm-like shape, popularly known as a '' flesh worm." Come- 
dones cause no symptoms. 

Acne is a chronic inflammatory disease of the sebaceous glands, 
due to the introduction of organisms from without; and it is 
those ducts which contain comedones which are most likelv" to 
become infected. The most common situation is the face, but 
the shoulders, back, and upper part of the chest are frequently 
involved. The disease makes its appearance at puberty when 
there is increased functioning of the sebaceous glands generally, 
and is characterized by papules, pustules, and small subcutaneous 
abscesses. The papules correspond with the mouths of the 
occluded ducts, are hard, tender, of a bright red colour, and 
surrounded by an inflammatory areola. The inflammation 
may subside and the process end here, or the papule may be- 
come a pustule which breaks and discharges ; or a small abscess 



COMMON DISEASES OF THE SKIN 




Acne. A case of moderate severity showing comedones, hard comedo-topped papules 

and small pustules. 



ACXE COMEDO 




4 COMMON DISEASES OF THE SKIN 

may form in the gland itself and show no tendency to point or 
break. As this small abscess increases in size, the papule above 
it becomes larger and less elevated, and a slight sense of fluctua- 
tion can be elicited. Ultimately, if the pus is not evacuated, 
the inflammatory reaction dies down and the pus is replaced by 
a cheesy material which can often be felt through the skin as a 
small, hard mass. A small pit or dimple, not unlike that left by 
a smallpox pustule, frequently appears in the skin over the site 
of the abscess, from destruction of the subcutaneous tissue. 
This latter condition is sometimes classed as a separate disease 
under the name of Acne varioKformis. 

The diagnosis is readily made from the distribution of the 
lesions, the age of the patient, and the character of the eruption. 
Acne rosacea is the only disease likely to be mistaken for it, 
the main points of difference being the later age at which rosacea 
appears, the comparatively few pustules, and the presence of the 
characteristic enlarged blood vessels. 

Treatment is often unsatisfactory. On account of the great 
liability of comedones to become infected, it is important to get 
rid of them. Many forms of comedo extractors can be obtained 
but most have the same defect; namely, that the opening 
through which the comedo is expressed is too large and pressure 
fails to dislodge it. We have found nothing to answer so well 
as a series of watchkeys of assorted sizes, selecting keys having 
considerable metal about the central opening as otherwise the 
pressure exerted in expressing the comedo is liable to cut the skin. 
Daily washing of the face with hot water and soap tends to in- 
crease the fluidity of the sebaceous matter and aid in the extrac- 
tion of the comedones. The popular idea that soap should 
never be used upon the face may have something to do with the 
production of comedones. For acne, in addition to daily steam- 
ing of the face, strong antiseptic applications are needed to pre- 
vent the purulent infection from extending. Alcohol pure, or 
wdth one or two grains of bichloride of mercury to the ounce, 
makes a good application, but must only be used once a day. In 
cases where there is much inflammation, calamine lotion (cala- 
mine preparata 40 grains, zinc oxide 30 grains, to the ounce of 



ACNE COMEDO 




Acne. Severe type showing, besides papules and pustules, numerous pits and scars 
following the healing of deep-seated abscesses. 



COMMON DISEASES OF THE SKIN 







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Acne. Severe type of long duration on the back, extends here lower than usual. 
There was a similar involvement of the front of the trunk. 



ALOPECIA 7 

lime water) -can be used at first in place of alcohol. Another 
good lotion contains precipitated sulphur one drachm and ether 
one drachm, to one ounce of rectified spirits, but in some people 
this tends to blacken the comedones. All pustules and subcu- 
taneous abscesses should be opened under antiseptic precautions 
and the contents squeezed out daily. The deep subcutaneous 
abscesses are conveniently emptied by inserting a straight Hage- 
dorn needle until the point is felt to enter the abscess cavity ; 
then, if the needle is rotated slightly, the pus can be forced out 
along its shaft while it is still in place. When the original open- 
ing of the duct is seen, it is better to insert the needle at this point. 
Often in severe cases of acne considerable improvement can be 
brought about by provoking sufficient inflammatory reaction in 
the skin to cause desquamation. For this purpose we use the 
escharotic paste known as Fordyce's, which contains betanaph- 
thol 4, resorcin 4 to 8, sulphur 12, paraffin and green soap of each 
13 parts. This is applied daily for from twenty minutes to an 
hour at a time until it produces intense redness and slight swell- 
ing. A few days after discontinuing it desquamation occurs. 
Treatment of whatever form requires to be kept up for a long 
time, a fresh crop of papules often appearing after the disease 
seems completely eradicated. Another form of treatment 
which gave great promise was the use of vaccines, either stock 
preparations of streptococcus and staphylococcus or one made 
from pus obtained from the lesions. In our experience this 
has proved disappointing, even when an autogenous vaccine 
is used, though we have had just enough success to warrant 
one in giving it a trial in resistant cases. We have had no ex- 
perience with vaccine made from the acne bacillus, but better re- 
sults are claimed for it. When the vaccine treatment is tried, 
it should be in conjunction with the other methods outlined 
above. 

ALOPECIA 

Alopecia, or Baldness, one of the results of passing years, is 
commonly not accepted by the individual affected without a 
struggle, and advice is often sought from the physician regarding 



COMMON DISEASES OF THE SKIN 




ALOPECIA AREATA 9 

its prevention and cure. Its advent before the usual age for 
its appearance has been attributed to many causes, but none of 
them, unless it be some concurrent disease of the scalp, give a 
satisfactory explanation. More often it is found to be a family 
characteristic. In some families the hair turns grey early in 
life but does not fall, in others there is early baldness, and no. 
method of treatment yet devised has been able to prevent either 
of these occurrences. Hence in cases of early baldness the family 
history should be gone into thoroughly and if a hereditary 
tendency is found, one should be chary about giving a favourable 
prognosis. Baldness or thinning of the hair following an acute 
or protracted illness is usually recovered from when the individual 
has regained vigorous health. The regrowth of the hair can be 
helped by stimulating lotions of which the following has proved 
of value in our hands. Tincture of cantharides i ounce, 
spirit of rosemary i| ounces, dilute acetic acid ij ounces, gly- 
cerine 10 minims, and rose water to 8 ounces. Close cutting or 
shaving of the head during an acute illness to prevent the hair 
from falling is of doubtful value, though the loss of hair is 
naturally Jess noticeable under such conditions. 

ALOPECIA AREATA 

Alopecia areata is a form of baldness in which the hair rapidly 
falls from an oval or circular area while the rest of the scalp is 
entirely unaffected. The loss of hair is so rapid that the affected 
spot becomes entirely denuded of hair in a few days, leaving the 
bare surface of the scalp smooth like parchment, and apparently 
depressed below the level of the surrounding skin. About the 
borders of the bald spot, if the disease is spreading, the hairs 
are readily pulled out and under the low power of the microscope 
they are found to have the shape of exclamation points ( ! ) . 
They show a gradual atrophy of the hair just above the bulbous 
root, which represents the dot of the exclamation point. After 
the disease has lasted months or even years, hair again begins 
to grow upon the bald spot, first in the form of a fine down with- 
out colour, but ultimately this becomes coarser, stronger, and 



lO 



COMMON DISEASES OF THE SKIN 




Alopecia areata. Regrowth of the hair has begun at the centres of the three patches. 
Complete recovery followed. 



ALOPECIA AREATA ii 

pigmented like the rest of the hair. Occasionally the new growth, 
though it gets coarse and strong, fails to develop pigment, giving 
the scalp a piebald appearance. The bald patches are almost 
invariably multiple and may coalesce as they extend, in time 
involving the entire scalp and producing total baldness ; and so 
too, the eyebrows, eyelashes, and beard may be involved. The 




Alopecia areata. Severe type of doubtful prognosis as the disease began at the 
margin of the hair and extended towards the vertex. 

disease tends to recur, and one frequently sees recently denuded 
and healing areas present at the same time. Most cases eventu- 
ally completely regain the lost hair, but there is one form of the 
disease in which the hair is rarely replaced and permanent bald- 
ness results ; namely, when the bald areas appear first at the 
margin of the hair and extend towards the crown. 



12 COMMON DISEASES OF THE SKIN 

The diagnosis is not difficult. In ringworm, which occasion- 
ally produces round bald areas, there is a much more gradual 
loss of hair, and careful examination will always reveal the char- 
acteristic stumps where the diseased hairs have broken off just 
above the surface of the scalp. 

Many methods of treatment have been advocated, and as most 
of the cases tend to get well spontaneously they are apparently 




Alopecia areata. Case likely to produce permanent baldness; the disease began 
at the margin of the hair, encircled the scalp and extended towards the centre. 

successful. In our experience equal parts of glycerine and 
carbolic acid painted over the bald areas once a day answers as 
well as anything. Shaving the head or close cropping the hair 
does not seem of any benefit ; the disease occurs in the beard of 



CARCINOMA 



13 



those who shave daily. It is well always to assure the pa- 
tient that recovery will follow in time, as worry and anxiety in 
many cases have proved the forerunners of a fresh attack, and, 
except in the exceptional cases already mentioned, one can 
reasonably promise a cure. 




Alopecia areata. Complete recovery of hair but with entire absence of pigment, 

a rare result. 



CARCINOMA 



Cancer of the skin is fairly common in the aged, owing to 
the tendency of either congenital or acquired moles and warty 
growths to become malignant in old people. With advancing 
years, senile or seborrhoeic warts appear on the face, upper part 



14 COMMON DISEASES OF THE SKIN 

of the thorax, and hands of most individuals. These warts are 
flat, soft, slightly elevated above the skin level, covered with a 
dark brown or black scale, often reach the size of a dime, and 
look like enormous freckles. Where malignancy supervenes, 
there is slight ulceration, with a thin, serous discharge which 




Carcinoma. Early papular stage of Rodent Ulcer, which later resulted in a char- 
acteristic ulcer with undermined edges. 



forms crusts, and concurrently the base of the wart and adjacent 
skin becomes slightly indurated. From such a beginning the 
malignant process slowly spreads, either as a gradually deepening 
and widening ulcer, or as a fungating, cauliflower-like growth. 

Another type of skin cancer begins as a pearly nodule of a 
pinkish white colour, showing dilated vessels running into it from 



CARCINOMA 15 

the surrounding skin. In the course of time, usually when it has 
reached the size of a large pea, the central portion breaks down, 
producing a small crater; and from this the ulceration extends 
until the nodule disappears and an excavated ulcer is left. 

Rodent ulcer, the commonest of all types of skin cancer, begins 
as a pearly grey, smooth nodule, usually situated on the face. 




Carcinoma. Rodent Ulcer which healed completely after treatment by acid nitrate 

of mercury. 

Ulceration takes place very early, and after the original tumour 
has disappeared, the process spreads slowly, the cancer cells 
invading the rete first, and thus leading to an ulcer with under- 
mined edges. Extension of the disease is always slow, cases 
which have existed five years often showing a lesion not larger 
than a five- cent piece. 



16 



COMMON DISEASES OF THE SKIN 



The above-mentioned forms of epitheliomata are of the basal- 
celled type and are frequently seen by the dermatologist ; 
prickle-celled cancers are met with earher in life, are not Hmited 
to the exposed parts of the body, and because of their more rapid 
growth, generally come first under the notice of the surgeon. 




Carcinoma. 



Rodent Ulcer, the left side of the nose was completely destroyed when 
the patient came under observation. 



Cancer of the skin requires to be distinguished from lupus 
and tertiary syphilis. Lupus is a disease of much earlier life, 
does not appear first as a wart or tumour mass, and the raised 
margins are composed of soft,, friable tissue. Deep ulceration is 
the exception in lupus, and it never shows marginal induration. 
Tertiary ulcerative syphilides are much more difficult to dif- 
ferentiate from cancer, as the two often resemble each other in 



CARCINOMA 



17 




Carcinoma. Rodent Ulcer, three-quarters life size, showing the undermined edge 

and ulcerated centre. 



1 8 COMMON DISEASES OF THE SKIN 




Carcinoma. Prickle-celled cancer of the scrotum in a man aged 30. 



CHLOASMA 19 

their clinicar features. Points which are of great value in deter- 
mining the nature of a doubtful case are its rate of extension 
and the number of individual lesions. Tertiary syphilis will 
cover in months an area which it would take years for cancer to 
produce ; and a single lesion is the exception in syphilis and the 
rule in cancer. Where there is a history of previous manifes- 
tations of syphihs, the case should be looked upon as such even 
though an interval of twenty years has elapsed. It should not 
be forgotten, moreover, that both lupoid and syphilitic ulcera- 
tion may at times be the starting points for carcinoma. 

Treatment depends upon the type of growth and the length of 
time it has existed. Small warts which are beginning to take 
on malignant characteristics are readily removed by freezing 
with liquid air or by chemical escharotics. Rodent ulcer, when 
small, responds well to such treatment. In the larger lesions, 
both of rodent ulcer and the other types, a much better plan 
is to scrape away the diseased tissues with a sharp spoon curette 
and cauterize the freshly denuded surface with acid nitrate of 
mercury. The escharotic action of the acid nitrate does not 
penetrate too deeply, and it can be at once neutralized by a paste 
made of bicarbonate of soda. A local or even general anaesthetic 
may be needed, but usually the patient can stand the slight pain 
without it and the soreness does not last. HeaKng of the wound 
occurs rapidly under a dressing of balsam of Peru ; and later any 
portion of the malignant growth which has escaped destruction 
can be dealt with again in the same manner. Repeated exposures 
to X-rays will produce an equally good result, but the treatment 
is more tedious and therefore less popular. There is practically 
no tendency to metastases in these basal-celled growths, but in 
all other forms it is unwise to trust to any form of treatment 
except complete and wide removal by surgical methods. 

CHLOASMA 

Chloasma is a term applied to increased pigmentation occur- 
ring either in circumscribed patches or diffusely, the colour 
varying from light brown to almost black. Certain parts of the 



20 



COMMON DISEASES OF THE SKIN 




CHLOASMA 21 

body are more prone to be affected and of these the face is the 
most often involved the pigment, appearing in patches and bands 
on the forehead, cheeks, and upper Hp. The condition is confined 
almost exclusively to females and is rare after the menopause, 
very common in pregnancy, and frequently associated with 
disease of the internal organs, especially the utero-ovarian sys- 




Chloasma. Pigmentation in bracket form on the forehead in a woman of 30. 

tem. The pigmented areas are popularly known as ''liver 
spots," from a supposed connection with disease of that viscus, 
but pigmentation is symptomatic of many systemic diseases and 
dermatoses. 

Pigmentation developing during pregnancy usually disappears 
a few months after parturition and requires no treatment. In 



22 



COMMON DISEASES OF THE SKIN 




DERMATITIS MEDICAMENTOSA 23 

cases of unknown origin, treatment of any existent uterine or 
other disease should be instituted with the idea of removing a 
possible cause. Locally the only way to remove the pigment is 
by causing desquamation of the skin over the affected area, and 
this can be accomplished either by an escharotic paste or by 
freezing. Fordyce's paste (see Acne) can be applied daily for 
from twenty to forty minutes until the resultant inflammation is 
sufficient to cause peeling as it subsides. Small areas are con- 
veniently treated with nitrous oxide snow or liquid air, care 
being taken to freeze the part just deep enough to destroy the 
superficial layer of the skin. 

DERMATITIS MEDICAMENTOSA 

Dermatitis medicamentosa is the term used to describe erup- 
tions produced by the ingestion of drugs or the absorption of them 
through the skin ; and it sometimes also includes the effects on the 
skin of irritants, such as iodine and croton oil, applied locally, 
but here the term is limited to the former class. Many drugs 
are partly eliminated from the body by means of the glands of 
the skin, and while some of these invariably produce eruptions 
if given in sufficient quantities, others do so only in certain in- 
dividuals who exhibit a special idiosyncrasy to their action. Of 
those occasionally toxic, there is a very large number and we 
shall confine our description to those most commonly seen. 
The amount of any drug, too, which can be ingested before it 
exerts an untoward effect upon the skin varies within wide limits, 
some individuals showing a remarkable tolerance in this respect ; 
and the presence of certain diseases seems to increase the in- 
dividual resistance, iodide of potash, for instance, being better 
borne by syphilitics. 

The Bromides, when taken for a long period of time or in ex- 
cessive doses, produce in adults a form of eruption which closely 
resembles a pustular acne, but differs from it in having a more 
general distribution and in showing a wider zone of inflammatory 
areola about the pustules. If the action of the drug is continued, 
the pustules become larger and raised, nodular areas form with 



24 



COMMON DISEASES OF THE SKIN 




DERMATITIS MEDICAMENTOSA 



25 




Dermatitis medicamentosa. Eruption following a day after inoculation against 
typhoid fever. It was of the erythemato-papular type and lasted for about 
ten days. 



26 COMMON DISEASES OF THE SKIN 

some superficial ulceration, the situation of these larger lesions 
being often determined by accidental bruising or scratching of 
the skin. In young children, bromide produces a different type 
of eruption. Raised, angry-looking, round, or oval patches, 
dark red in colour and crowned with small drop-like pustules 
develop on the limbs and trunk. These may reach the size of a 
fifty-cent piece and be so numerous as to cover the body almost 
entirely. When the drug has been discontinued, they rapidly 
dry up and disappear without leaving any scar. 

The Iodides produce an eruption much like the bromides, and 
pustular, acniform, furuncular, or ulcerative lesions are seen in 
proportion to the amount of the drug ingested. Where there is 
excessive dosage or great intolerance to the drug, raised, fungoid 
swellings exuding pus may develop about the mouth and nostrils, 
and on the forehead and cheeks. 

Most of the resinous drugs, Copaiba, Turpentine, etc., produce 
either an intense patchy erythema, somewhat resembKng 
scarlet fever, or an erythematous, macular eruption simulating 
measles, the latter being especially the case with copaiba where 
the resemblance to measles is very close. Belladonna also fre- 
quently produces an erythema, but the skin is not liable to be 
affected until after the other untoward symptoms of the drug 
have appeared. Arsenic produces a keratosis of the palms and 
soles with a patchy erythema over the body with induration and 
superficial scaling, and its long continuance often leads to pig- 
mentation, even without the previous appearance of an in- 
flammatory stage. The eruptions following the use of diph- 
theria antitoxin and the vaccines for conferring immunity are 
mostly of the urticarial or erythema multiforme type and only 
last for a few days. 

The diagnosis of dermatitis medicamentosa is readily estab- 
lished when the eruption follows the exhibition of the drug or 
serum at an interval of a few hours or days ; often, however, the 
active agent is concealed in a patent medicine and the true ex- 
planation of the rash is not suspected. In this connection it 
should be remembered that practically all the so-called " blood 
purifiers " and " Sarsaparilla Compounds " contain iodide of 



DERMATITIS MEDICAMENTOSA 27 




Dermatitis medicamentosa. Detail of the last, three-quarters life size. The lesions 
covered the whole body except the face, hands, and feet. 



^8 COMMON DISEASES OF THE SKIN 

potash, and the '' Epilepsy Cures " bromides. An acniform 
eruption that extends below the level of the waist is suggestive 
of either iodide or bromide poisoning. The absence of pyrexia 
and constitutional symptoms will enable one to draw the line 
between the morbilHform and scarlatinoid rashes and the ex- 
anthemata themselves. 

Treatment consists in remoxdng the exciting cause* 

DERMATITIS REPENS 

Dermatitis repens is a mild form of creeping infection con- 
fined to the superficial layers of the epidermis. Commonly 
seen upon the hands, it usually begins at the site of some sHght 
injury, and thus very frequently starts at the borders of the nails. 
The inflammation causes very httle appreciable redness but 
produces a thin watery pus, which separates the outer layer of 
the skin from the underlying rete. The bullae thus produced are 
only partly filled, scarcely rising above the skin level, and show no 
tendency to spontaneous rupture. When the covering skin is 
removed, the surface underneath is vividly red and smooth but 
does not bleed, though it is acutely sensitive to touch ; but it 
soon loses this character and becomes covered with a corneal 
layer. When no rupture takes place, heahng occurs in a similar 
manner and the dried outer skin is thrown off. The disease 
spreads rapidly at the periphery ; when starting at the root of 
the nail, it soon encircles the finger, constituting the familiar 
'' run round. '^ There is usually more than a single lesion and 
both hands are commonly infected. When neglected, the disease 
may assume formidable proportions, especially as some of the 
accidentally denuded areas are likely to become infected with a 
more virulent form of pyogenic organism, and invasion of the 
deeper tissues, causing celluHtis and lymphangitis, occur. The 
disease is much commoner in children than adults, but is met 
with at all ages and occasionally seen on any part of the body. 

There is Httle difficulty in recognizing the nature of the affec- 
tion ; a bullous erysipelas or any of the other diseases in which 
bullae form, is characterized by severe constitutional symptoms 



DERMATITIS REPENS 



29 




so COMMON DISEASES OF THE SKIN 

and, locally, by a wide area of surrounding hyperaemia ; whereas 
in dermatitis repens the outer layer is hfted by the exudate 
without any antecedent redness. 

Treatment consists in cutting away the loosened skin and 
applying antiseptic solutions to the denuded area. Moist 
dressings of i to 5000 bichloride of mercury in water kept in 
contact with the part for twenty-four hours will arrest its 
progress. By seeing the case daily any extension of the disease 
can be similarly dealt with, and healing can be aided, once the 
extension has ceased, by mild antiseptic ointments. 

DERMATITIS VENENATA 

Dermatitis venenata is that form of inflammation of the 
skin produced by the poisonous juice of certain plants, 
or by the irritant action of certain drugs or chemicals when 
brought in contact with the skin. In Canada and the United 
States there are but three plants commonly met with that 
poison those who come in contact with them. Poison Ivy 
(Rhus toxicodendron), which grows as a recumbent creeper along 
the banks of rivers and in low grounds, is not unlike the com- 
mon Virginia creeper, but its compound leaves have three in- 
stead of five leaflets. Poison Elder (Rhus venenata), a small 
shrub from six to eighteen feet in height, having compound 
leaves with seven to thirteen leaflets, is found in swamps and 
is not a native of Canada. The Chinese Primrose (Primula 
obconica) is not a native of North America but is cultivated 
as an ornamental plant in conservatories. Of the three, the 
poison elder is much the most virulent, while the primrose is the 
least. Liability to poisoning varies widely ; some people are 
immune, while others are so susceptible that they do not require 
actually to touch the plant to be affected by it. 

The eruption produced by contact with poison ivy and poison 
elder begins as an intense erythema which stings and burns, 
and in a short time, usually within twenty-four hours, vesicles 
appear on the inflamed surface. They are tensely filled with a 
clear fluid, increase rapidly in size, and often coalesce to form 



DERMATITIS VENENATA 



31 




32 



COMMON DISEASES OF THE SKIN 




Dermatitis venenata. Poison ivy. Eruption developed on both hands and lower 
part of the face after a day in the country. The larger bullae were loculated and 
required to be punctured in several places to evacuate the contents, but left no 
scars. 



DERMATITIS VENENATA 



S3 




Dennatitis venenata. Poison ivy. Whole face including the ears exhibited an in- 
tense erythema with a few vesicles. Hands were primarily affected and carried 
the poison to the face and genitals where a like condition was present. Subject 
a boy, aged g. 



34 



COMMON DISEASES OF THE SKIN 



large blebs ; while the underlying tissues become swollen and oede- 
matous, and when the face is affected the eyes are closed by the 
swelling. After several days the intensity of the disease sub- 
sides, and as the part gradually gets well, desquamation occurs. 
While the exposed parts of the body are primarily affected, the 
poison is frequently carried by the hands to other parts, espe- 




Poison Ivy. Rhus toxicodendron, one-quarter natural size. 



cially to the genitals, where a. similar but less severe eruption 
is produced. 

Poisoning by the Chinese primrose never assumes so severe a 
form, and only the hands and face are hkely to be involved, 
while the eruption resembles an erythematous eczema and is 
rarely vesicular. There is redness of the skin associated with 
burning and itching often lasting several days, and as the cause 
's not often suspected, the case is looked upon as one of eczema. 



DERMATITIS VENENATA 



35 



Any acute erythematous eruption occurring on the hands and 
face, in an individual who has not been subject to it and who has 
to do with the care of ornamental flowers, should be investi- 
gated with a view to the possibihty of primrose poisoning. 

A dermatitis may be set up by the local apphcation of drugs 
from using them either in too great strength or in an injudicious 
manner. Many drugs which normally produce no irritation 



.^^ 


£m 






^^^Bji^^dH^l 11 ^^^r 




fc/^ 


HShI^ 


^^Sm 


H i^ 


^ "^ 


T^|3^ 



Chinese Primrose. Primula obconica, one-third natural size. 



of the skin, may do so if applied under an air-tight covering, 
and this effect is increased when the surface is already inflamed. 
We have seen many instances of the conversion of a mild 
erythematous eczema into a severe purulent type by such a 
bland apphcation as calamine lotion, when used in this way. 
Often it is not possible to avoid producing a dermatitis, as in 
the chrysarobin treatment of psoriasis. Dermatitis venenata 
includes also the very large group of occupation dermatites, 



36 



COMMON DISEASES OF THE SKIN 




ECZEMA 37 

eczematoid eruptions induced by prolonged exposure to the 
various irritants incidental to many trades. 

In the treatment of ivy poisoning the essential point is to 
soothe the inflammation and prevent its spread. If seen early, 
the surface should be brushed over with alcohol to neutralize any 
of the poisonous juice still present, and prevent its being carried 
to other parts of the body. Of soothing applications, first place 
must be given to lead lotion, one part of hquor plumbi subacetatis 
to forty parts of water. This should be applied on lint which 
is kept constantly moist by repeatedly wetting it with the 
lotion. Many other drugs in weak solution have been found of 
value, such as boric acid, calamine, sodium hyposulphite, black 
wash, and lime water. The blebs should be punctured and the 
contents evacuated. The dermatitis subsides spontaneously 
when let alone, so many " cures " are vaunted. 

ECZEMA 

In the older text-books. Eczema included a large class of re- 
lated diseases all showing the same type of inflammation. 
Latterly, as the causes which produce them have become better 
understood, the tendency has been to class many of these as 
dermatites with a quaHfying word indicating the specific origin, 
i.e. dermatitis traumatica. This, however, has not solved the 
problem of what should be included under eczema, and the way 
in which the difficulty arises can be best explained by citing an 
example. Iodoform, used as a surgical dressing, often produces 
a dermatitis which clinically is indistinguishable from eczema, 
but when the irritant is removed, while most of the cases clear 
up spontaneously, in some the dermatitis not only continues to 
exist but extends beyond its original limits ; in fact, it behaves 
just as an eczema, though it began as a dermatitis due to a 
definite cause. Moreover, it is found that it is in those persons 
who are subject to attacks of eczema that this extension and 
persistence of the inflammation is apt to occur : hence, it seems 
wiser with our present knowledge to include under eczema both 
all cases of unknown etiology, and those which behave as such 
even when the exciting cause can be determined. 



38 



COMMON DISEASES OF THE SKIN 




Eczema. Chronic erythematous type. Note the deepening of the natural lines 
in the forehead from the induration. 



ECZEMA 



2>^ 




40 COMMON DISEASES OF THE SKIN 

Eczema presents so many clinical types in its acute and chronic 
forms that two areas in one individual may have a totally different 
appearance. There are the erythematous, papular, vesicular, and 
pustular forms of the disease in acute cases, and the squamous 
in chronic cases. One form does not remain constant through- 
out an attack, but may change to another. The disease begins 
either as an inflammatory erythematous area or by the develop- 
ment of small, uniformly sized papules on the normal skin, 
with or without hyperaemia. In all cases there is intolerable 
itching and efforts to relieve this by rubbing or scratching only 
result in augmenting it. Either of these types may persist for a 
time without change and the disease then subside ; usually, 
however, in the erythematous type small, pinhead-sized vesicles 
with thin walls form on the inflamed base, and the spontaneous 
rupture of these leads to the formation of yellowish crusts from 
the dried exudate. When the crust is removed, it reveals a 
reddened moist surface from which a serous, sticky fluid constantly 
exudes, the vesicular moist, or '' weeping " type of the disease. 
In other cases beginning in papular form, the papules may be- 
come confluent and a raised indurated patch result. This in 
turn may become vesicular or remain dry, and give rise to super- 
ficial scaHng, the squamous type. Again, in place of vesicles, 
pustules may form and the disease is then classed as pustular ; 
though cases of this sort are probably due to accidental in- 
fection with pus-producing organisms. In all types which have 
existed for any length of time, thickening of the skin or indura- 
tion results. The effect of this is deepening of the natural 
lines and furrows of the skin and loss of its elasticity, and when 
the parts involved are subject to strain, as over the joints, or to 
pressure, as on the finger-tips or toes, the indurated skin splits 
instead of stretching, giving rise to cracks or fissures. It is not 
usual to find the disease limited to one primary type, more often 
it can be described as erythemato-papular, papulo-squamous, etc. 
So also in the moist form the discharge is frequently sero- 
purulent rather than serous, owing to secondary infection. 

While all forms of eczema may attack any part of the body, 
certain regions are found to have a predominating type. In 



ECZEMA 



41 




42 



COMMON DISEASES OF THE SKIN 




ECZEMA 



43 




£c7ema. Vesicular crusting type on the face. The crusts were yellow and 
consisted of dried exudate. Rapid recovery under treatment 



44 COMMON DISEASES OF THE SKIN 

infants the moist crusting form is seen about the scalp and face, 
particularly on the cheeks. In older children these situations 
are more apt to present the erythematous variety, and the limbs 
and buttocks the papular form, the extensor rather than the flexor 
surfaces being involved. In adult life palmar eczema is com- 
monly of the dry, fissured form, while the lateral borders of the 
fingers, wrists, and dorsum of the hand show the vesicular type. 
About the genitals, the erythematous or moist types are most 
common. On the legs below the knee, chronic eczema produces 
the condition known as eczema rubrUm, an intensely red, dry, 
glazed surface alternating with moist crusting. Acute attacks 
of eczema give rise to considerable swelling of the parts affected, 
and this is especially the case when the face is involved, where the 
swelling may completely close the eyes. Of subjective symptoms, 
itching varying in intensity with the type is always a marked 
feature. Deep fissures are often extremely painful. 

In making a diagnosis one must bear in mind that eczema 
forms nearly two-fifths of all skin diseases, hence in doubtful 
cases it must first be excluded. Reliance is to be put on getting, 
either in the previous history of the case or in the present con- 
dition, evidence of weeping associated with induration and 
severe itching. Again, eczema is the only vesicular skin disease 
in which after the vesicles have once ruptured there is a contin- 
uous or intermittent oozing from the diseased part. Many 
dermatoses resemble some stage of this protean disease, and the 
means of dift'erentiating them from it are discussed under these 
diseases. Seborrhoeic dermatitis is especially related to eczema 
which it closely resembles ; the points of difference are noted 
under that disease. 

A full consideration of the treatment of eczema is beyond the 
scope of a small volume. A brief review of the lines along which it 
is to be carried out, indicating a few of what we have found the 
most effective remedies, is all that will be attempted. Local 
treatment must be varied according to the type, but in all 
varieties protection of the diseased parts from sun, wind, soap, 
and water, all of which act as irritants and aggravate the condi- 
tion, is essential. The use of elaborate dressings is to be avoided, 



ECZEMA 



45 




46 



COMMON DISEASES OF THE SKIN 




i 



ECZEMA 



47 




48 



COMMON DISEASES OF THE SKIN 




ECZEMA 49 

especially in the moist forms, where a mild, subacute attack may 
be converted into a severe, purulent form. It is a good rule 
never to apply a dressing to a case that cannot be inspected 
daily. 

In the acute erythematous form of the disease, dusting powders 
and soothing lotions give good results. A good powder, suggested 
by Stelwagon, consists of boric acid i, zinc oxide 2, and talc 5, 
but it should not be used where there is any exudate, as it tends 
to form stiff crusts which cause extreme irritation. Lead lotion 
plain, or with the addition of a drachm of liquor carbonis deter- 
gens to the pint, plain olive oil, or olive oil 2, lime water i, will 
be found very soothing. 

In vesicular eczema of the acute weeping type, the part re- 
quires to be kept constantly covered with a soothing ointment 
or liniment. Hebra's ointment, made by heating together lead 
plaster i, olive oil 2, with the addition of one per cent of oil of 
lavender to disguise the unpleasant odour, is protective, healing, 
and non-irritating to the inflamed surface. Calamine liniment 
(calamine 40 grains, zinc oxide 30 grains, Hme water 2^ drachms, 
and olive oil 5^ drachms) is most soothing. The parts should 
be kept moist by repeated applications, or by covering them with 
a layer of gutta percha tissue or thin oil silk kept in position 
with a gauze bandage. Strips of lint or gauze soaked in the Kni- 
ment or ointment and applied under the oil silk are apt to over- 
heat the part and act like a poultice. When a fresh dressing is 
needed, usually two or three times in twenty-four hours, the part 
is cleansed with olive oil before applying it. 

In the papular form where there is no moisture and the main 
complaint is the intolerable itching, tar in some form requires to 
be added to the application. Ointments here answer best, as 
they prolong the action, owing to their slow drying proper- 
ties. Ungt. zinci cum hydrargyri (ungt. hydrargyri ammoniatum 
2 drachms, ungt. zinci and ungt. aqua rosae, of each, 3 drachms) 
is mildly antiseptic and non-irritating, and to it as a base from a 
half to one drachm of either oil of cade or liquor carbonis deter- 
gens can be added to each ounce. 

In the squamous chronic type with induration and fissures, 



5^ 



COMMON DISEASES OF THE SKIN 




Eczema. Erythematous type with induration. The disease began at the nipples 
in a nursing mother and spread over almost the whole surface of the glands. 



ECZEMA 



51 




Eczema. Squamous type, 



early stage. No moisture, 
produce shallow fissures. 



but sufficient induration to 



52 



COMMON DISEASES OF THE SKIN 




ECZEMA 



53 




Eczema. Vesicular form on the palms. 



54 COMMON DISEASES OF THE SKIN 

stronger applications again are required. An excellent plan of 
treatment is to paint the parts with liquor carbonis detergens 
once or twice daily and in the intervals keep them constantly 
soaked with the above ointment, cold cream, or lanoline. As this 
form of the disease is mostly met with on the hands, the patient 
should be advised to wear loosely fitting kid gloves, with the 
tips of the fingers cut off unless they also require treatment, and 
allow the gloves to become thoroughly soaked with the ointment. 

Regional eczema requires special procedures in the way of 
treatment according to its situation. Old chronic cases of eczema 
of the lower legs, due to varicose veins, can often be healed by 
applying a rubber web bandage over the dressing and reducing 
the blood supply. In eczema of the scrotum and adjacent parts 
of the thighs, the wearing of a thin net suspensory to keep the 
scrotum from touching the thighs prevents chafing and secures 
rest to the inflamed surfaces. 

Infantile eczema presents almost insuperable problems in 
treatment. Contrary to what is generally taught, in our ex- 
perience it is robust rather than weak infants who suffer from it, 
and often it attacks breast-fed children living under apparently 
ideal conditions. The eczema, which usually appears first on 
the cheeks and spreads in some cases to cover almost the entire 
body, is of the moist type, beginning during the first six months 
of life and lasting often until the child is eighteen months old. 
The activity of the disease varies within wide limits, some- 
times entirely subsiding and reappearing without adequate 
explanation. Many cases are undoubtedly of reflex origin, 
as shown by those in which the eruption of each succeed- 
ing tooth is coincident with a flare-up of the eczema, though 
the child's general condition is not upset by the dentition. 
Soothing ointments and liniments are indicated ; calamine 
liniment and ungt. zinci cum hydrargyri are often of great ser- 
vice. Measures should be taken to prevent the child's scratch- 
ing the affected parts, and as masks for the face are difiicult to 
adjust and keep in place, this can be accomphshed by fastening 
the sleeves of the dress so that the hands cannot be raised to the 
level of the head. Even with this precaution the face is rubbed 



ECZEMA 



55 




Eczema. Variety rubrum on the lower leg. The lesion was of a brilliant red colour 
with a glazed surface which, as can be seen, reflected the light. This alternated 
with periods of profuse exudation. 



S6 



COMMON DISEASES OF THE SKIN 




ECZEMA 



57 




Eczema. Erythemato-vesicular type in an infant of six months, 
common situation in infantile eczema. 



This is the most 



58 COMMON DISEASES OF THE SKIN 

against the pillow or clothing and the use of a very stiff oint- 
ment may be tried to keep the diseased parts covered. Ihle's 
paste, made with two drachms each of lanolin, vaselin, zinc 
oxide, and starch, to which boric acid, salicylic acid, etc. can be 
added, can be smeared on thickly and will adhere better and 
prove more protective than a thinner ointment. 

ECZEMA SEBORRHOICUM 

Eczema seborrhoicum, known also as Dermatitis seborrhoica, 
is closely allied to eczema on the one hand and seborrhoea on 
the other. It resembles eczema in that it shows the same 
catarrhal type of inflammation and, objectively, is hardly 
distinguishable from it, while it is frequently a sequel of sebor- 
rhoea. The disease resembles the moist form of eczema, but 
differs from this in showing less tendency to induration and in the 
character of the exudate, which has more of an oily consistency 
as seen in some forms of seborrhoea. Subjectively it does not 
give rise to such severe itching. It is most commonly met with 
in the hairy parts of the body, scalp, axillae, and pubes, and from 
these spreads by continuity to the adjacent skin. In its appear- 
ance and mode of extension it suggests strongly a microbic 
origin, and patches of the disease occurring on the glabrous skin 
often resemble ringworm. In a typical case involving, one of 
the hairy regions of the body, one sees a surface coated with oily 
crusts or thick exudate, which on removal discloses a moist, 
secreting, reddened base. The disease is very persistent and 
may remain chronic for months, confined to scalp, pubes, or 
axillae, with an occasional flare-up in an acute exacerbation, when 
it invades the neighbouring glabrous skin. When the disease 
is primary in non-hairy parts of the body its favourite sites are 
the anterior and posterior regions of the upper parts of the 
thorax and the sides and angles of the nose. Here the eruption 
is drier and the exudate not so profuse, and the margins are 
sharply defined and have a wavy outline. 

The disease is recognized from its distribution and its resem- 
blance to eczema, from which it differs in the absence of marked 



ECZEMA SEBORRHOICUM 



59 




Eczema seborrhoicum. The disease resulted from a milk crust, ultimately spread- 
ing over the face; a small ofifshoot has already invaded the glabrous skin. 



6o 



COMMON DISEASES OF THE SKIN 




Eczema seborrhoicum. 



Acute attack with well-defined margins and exhibiting 
more crusting than usual. 



ECZEMA SEBORRHOICUM 



6i 



infiltration and in having a well defined border. In those rarer 
forms in which it occurs primarily in regions without coarse 
hair, it might be confused with ringworm or pityriasis rosea. 
The former, on microscopical examination, shows the specific 
fungus, and in the latter the lesions are not sharply defined and 
the scales are less numerous, thin, and not greasy. Moreover, 




Eczema seborrhoicum. The subject had had the disease in the scalp, axillae, and 
pubic hair for months. The photograph was taken during an acute exacer- 
bation when the face and neck and regions about the axillae and thighs became 
involved. The eruption was erythemato-vesicular in character. 

the distribution of pityriasis rosea is so constant that rehance 
can be placed on this feature to differentiate the two diseases. 

In its reaction to treatment as well as in its physical characters 
eczema seborrhoicum strongly suggests a specific germ which is 
destroyed by sufficiently strong antiseptics. Sulphur, resorcin, 
and mercury are all of proved value in combating the disease. 
Sulphur may be used in the form of an ointment, 30 to 60 grains 
to the ounce, beginning with the weaker preparation. Resorcin 
is especially of use on the scalp in the form of a lotion (resorcin 
20 grains, acetic acid 30 minims, rectified spirits 2 drachms, 
castor oil 3 minims, to the ounce of water), sponged in several 



62 COMMON DISEASES OF THE SKIN 

times a day. Mercury answers well when used in the form of the 
oleate, 5 to 20 grains to the ounce. The weaker preparation 
should be tried first and the strength gradually increased. In 
this connection it may be noted that much stronger applications 
can be borne without irritation on the hairy regions of the body 
than on the glabrous skin. 

ERYTHEMA MULTIFORME 

Erythema multiforme is an acute inflammatory disease 
presenting a great variety of forms. In the majority of cases it 
appears first as a macular or patchy erythema, which is often 
slightly raised above the level of the surrounding skin, and as the 




Erythema multiforme. Erythematous type which subsided without change in 

few days. 



ERYTHEMA MULTIFORME 



63 



disease progresses the border becomes of a darker red than the 
rest of the lesion, defining the edge more sharply. The process 
may end here and the coloration gradually fade, or a second zone 
of colour, lighter or darker than the general hue of the lesion and 
parallel with its border, may develop ; and this again may be 
followed by a third and even a fourth, giving it somewhat the ap- 




Erythema multiforme. 



Erythematous type, associated here with a gastro- 
intestinal disturbance. 



pearance of a target in the arrangement of the rings. In other 
cases, as the development proceeds in some of the zones the 
erythema may be replaced by vesicles, pustules, bullae, or even 
haemorrhages, which also follow the concentric arrangement. 
Round lesions of this description, having a row of small herpetic 
vesicles at the periphery and a dark, often haemorrhagic, centre, 



64 COMMON DISEASES OF THE SKIN 




Erythema multiforme. Erythematous type showing the increase in depth of colour 
at the margins' of the lesions. 



ERYTHEMA MULTIFORME 



6S 




66 



COMMON DISEASES OF THE SKIN 




ERYTHEMA MULTIFORME 



67 




68 COMMON DISEASES OF THE SKIN 

suggested the name herpes iris often applied to this variety of the 
disease. When the vesicular form of the disease attacks the palms 
of the hands and soles of the feet, the vesicles do not break but 
fuse to form a single, large, ring-shaped lesion. If the individual 
lesions are close enough together to overlap, there is difficulty in 
making out the characteristic arrangement in concentric patterns, 
as the border then assumes a wavy outline. 

The disease is the cutaneous manifestation of some general 
toxaemia and its onset is usually accompanied by malaise, rise of 
temperature, and pain in the joints. The eruption gives rise to 
burning and stinging sensations rather than itching, and causes 
as a rule Uttle discomfort. It is symmetrical in distribution and 
the extremities are more frequently affected than the trunk, 
though the whole surface of the body may be covered with the 
rash, which in the majority of the cases appears first on the backs 
of the hands and the wrists, and is often seen here and about the 
head and neck, when the rest of the body is entirely free. The 
herpetic form is much more common on the extremities, the 
diffuse on the trunk. Erythema multiforme is the eruption 
produced by ptomaine poisoning, the injection of diphtheria 
antitoxin, the inoculations against typhoid and other diseases 
and the use of salvarsan intravenously ; it is also seen as a ter- 
minal event in septicaemia. In most cases, however, the cause 
cannot be discovered and often the constitutional symptoms are 
so slight as to escape notice. The disease runs a definite course, 
rarely lasting more than two weeks and changes in the character 
of the eruption can be noted from day to day. 

If the characteristic zones of different colour are present, the 
diagnosis is at once clear. The cases causing the most difficulty 
are those in which the disease is very extensive and where the major 
part of the eruption does not present this feature ; but in these a 
careful search will generally reveal it in some of the outlying areas. 
One of the secondary syphihdes, commonly seen about the head 
and neck, is an erythematous, circinate eruption not unlike 
erythema multiforme. Where other evidence of S3rphiHs cannot 
be obtained, its slow development and its persistence in the 
same form for weeks, will exclude erythema multiforme. Urti- 



ERYTHEMA MULTIFORME 



69 




70 



COMMON DISEASES OF THE SKIN 




ERYTHEMA MULTIFORME 



71 




72 



COMMON DISEASES OF THE SKIN 




ERYTHEMA NODOSUM 73 

caria gives rise to raised erythematous wheals, which, however, 
are extremely evanescent and of a more or less uniform colour. 
Ringworm forms circles, occasionally concentric ones, but the 
presence of scales serves to distinguish it. The ring form of 
impetigo has some resemblance to it, but here the centre of the 
ring is not of an erythematous character and the distribution is 
not symmetrical. 

Treatment is confined to cooling applications, like evaporating 
lead lotion, calamine lotion, and similar preparations. It is 
doubtful if they influence the course of the disease and often, in 
the absence of subjective symptoms, they can be dispensed with 
altogether. Where nothing can readily be assigned as the cause 
of the disease, it is well to administer a sahne cathartic on the 
chance of its being due to an intestinal toxin ; and as many cases 
seem to have a remote connection with rheumatism, in that they 
occur in persons suffering from subacute or chronic forms of this 
disease, here salicylates may be tried. 

ERYTHEMA NODOSUM 

Erythema nodosum is an acute, inflammatory disease occurring 
mostly on the extensor surfaces of the legs and forearms. An 
attack is ushered in with fever, malaise, and pain in the joints, 
followed in a few hours by slightly raised, bright red tumours, 
resembling developing furuncles, on the anterior surface of the 
legs below the knee. These lesions are acutely tender to touch, 
vary in size up to that of a silver dollar, and may give a sense of 
fluctuation though they never suppurate. The bright red colour 
changes in a few days to bluish red or purple, going through the 
same changes that one sees in a fading bruise, a greenish yellow 
stain often remaining for some time after the tenderness has 
disappeared. The lesions are always most numerous over the 
crests of the tibiae, but they also occur on the extensor surface 
of the forearms, and may be found in rare cases elsewhere over 
the body. The affection bears a close relationship to rheumatic 
fever and allied diseases, often occurring before, during, or after 
an attack of one of these. It is commonly met with in older 



74 



COMMON DISEASES OF THE SKIN 




ERYTHEMA NODOSUM 



75 




76 COMMON DISEASES OF THE SKIN 

children or young adults, and females seem more susceptible 
than males. 

The distribution and peculiar character of the lesions, coupled 
with the febrile onset, readily determine the diagnosis. 

Treatment consists of rest in a reclining position with soothing 
applications to the inflamed areas. Nothing answers better than 
lead lotion (liquor plumbi subacetatis, one, to forty parts of 
water) or the evaporating lead lotion, in which 25 per cent of 
alcohol is added. The eruption should be kept covered with cloths 
wet with the lotion. Internally it is our practice to give sahcylate 
of soda in full doses, but, as the disease tends to run a definite 
course, it is questionable whether this drug has any influence 
upon it. 

FAVUS 

Favus is a contagious, parasitic disease of the skin due to a 
vegetable fungus the Achorion Schonleinii and is characterized 
by the growth, mostly on the scalp but occasionally on the 
body, of colonies of the fungus which produce small, saucer- 
shaped, sulphur-yellow crusts, firmly adherent to the skin. 
The mycelia grow through the whole thickness of the skin and 
invade the hairs and hair follicles, destroying the tissues and 
rendering the hairs brittle so that they break or fall out. When 
healing occurs small irregular cicatricial bald patches are left 
as a permanent evidence of the former presence of the disease. 
The affection is one of early life, beginning before fifteen years of 
age and lasting until twenty-five or thirty, slowly extending over 
the scalp and leaving in its path the bald areas already mentioned. 
It is quite common among the emigrant class in the larger centres 
of population, especially so in the Hebrews from Poland, Rou- 
mania, and neighbouring countries, but rare in the native born, 
most of these we have seen being French Canadians from the 
Gaspe peninsula. It is undoubtedly contagious, but not to any 
great extent, as it is quite common to find only one child affected 
among a large family. 

The diagnosis in the long-standing cases, where the baldness 
like moth-eaten fur is present, is not difficult. Early cases can 



FAVUS 



77 




Favus. 



Shows the saucer-hke growth of the fungus and the form of baldness in 
very marked case. Three-quarters life size. 



78 



COMMON DISEASES OF THE SKIN 




Favus. Showb lesions involving the region of the beard and one at the outer 
canthus. Subject had old chronic patches in the scalp. 



FAVUS 79 

be distinguished from ringworm by the adherent character of 
the sulphur coloured crusts, whose removal causes bleeding, and 
by microscopical examination of the fungus, which grows in 
branched filaments much stouter and shorter than in ringworm 
and with the spores arranged in clusters instead of in chains. 




Favus. Severe case involving almost the whole scalp. Subject a French-Canadian 

girl, aged 19. 

The treatment follows much the same lines as in ringworm 
(which see), removal of the diseased hairs, preferably by X-rays, 
and strong germicidal applications to the diseased areas daily, 
preceded by a thorough washing of the part with green soap and 
water. An ointment consisting of equal parts of carbolic acid, 
sulphur ointment, and citrine ointment will keep the disease in 
check and if persistently used for months effect a cure. 



8o 



COMMON DISEASES OF THE SKIN 



FURUNCULUS 

Furunculus, or Boil, hardly needs description, being familiar 
to every one. It consists of an acute inflammation of the 
tissues surrounding a hair follicle or sweat duct, resulting in 
necrosis and pus formation in the centre, and terminating in 




Furunculus. Multiple boils on the lower leg of a child aged 7. 



rupture and discharge of the necrosed tissues. There is usually 
more than a single lesion, one boil leading to the production of 
others in the same neighbourhood through infection of the adja- 
cent hair follicles ; and in people of uncleanly habits, more 
especially in children, furuncles may develop all over the body. 
The infection is entirely a localized one in spite of the popular 
opinion that its source lies in the blood. The pain experienced 



FURUNCULUS 



8i 




82 COMMON DISEASES OF THE SKIN 

varies widely with the situation of the lesion ; where there is but 
Httle soft tissue overlying the bone, as in the auditory canal, 
and where the inflamed area is frequently disturbed by muscular 
contractions, as on the face, the pain is very severe. 

Treatment is to be directed towards alleviating the pain and 
prote:ting the patient against accidental autoinoculation. The 
first indication is met by keeping the inflamed parts at rest as far 
as possible, and this can be accomplished by covering it with a 
thick dressing of one of the stiff pastes (Cataplasma kaolini, 
U. S.), which are applied hot and on cooling act as a splint, 
providing both protection and immobility. As complete relief 
from the pain is only obtained after the boil has ruptured, one 
may attempt to hasten this by hot boracic fomentations, but in 
our experience very little is gained in this way. The skin sur- 
rounding the boil may be protected from infection by smearing 
it daily with white precipitate ointment before applying the 
dressing and by carefully disinfecting the part and discharges 
with some strong antiseptic solution whenever it is handled. 
Surgical treatment by incision has been losing favour of late 
years and it certainly adds very appreciably to the painfulness 
of the disease, does not shorten it, and is apt to produce more 
noticeable scars. The use of a vaccine made from cultures of 
staphylococcus pyogenes aureus, the organism most commonly 
recovered from the pus, has proved of benefit in some cases, but 
routine treatment in this manner has been disappointing with us. 
It is worthy of trial, however, in all severe cases, and is more 
likely to be of service if the vaccine be made from pus obtained 
from the individual. 

HERPES SIMPLEX 

Herpes simplex is an acute inflammatory disease, characterized 
by an eruption of vesicles about the face or genitals, and usually 
associated with some disturbance of the general health. The 
attack begins with a stinging or burning sensation at the points 
where, within a few hours, groups of tensely fifled vesicles appear. 
These contain a clear serum, later becoming cloudy and generally 



HERPES SIMPLEX 



83 




Herpes simplex. Showing the commonest form of the disease, one or two groups 
of vesicles about the mouth, encroaching on the mucous membrane. 



84 



COMMON DISEASES OF THE SKIN 




Herpes simplex. Shows the clusters of herpetic vesicles, here dried to form yellow 

crusts. 



HERPES ZOSTER 



85 




Herpes zoster. Typical case. 



86 COMMON DISEASES OF THE SKIN 

escaping to form yellowish crusts, which on falling leave no scars. 
The lesions are commonly multiple and most frequent about the 
mouth and nostrils at the junction of the skin and mucous 
membrane. Many persons are subject to repeated attacks, any 
shght ailment causing a fresh outbreak, hence the popular 
name of '' cold sores " or " fever blisters." Herpes is a frequent 
symptom of pneumonia and is seen also in typhoid fever and 
many of the infectious diseases. Its occurrence on the genitalia 
is much less common, but here it is also prone to recur in those 
subject to it, and seems to be induced by sexual excitement. 
The lesions are smaller, multiple, and occur as single vesicles on an 
inflamed base. They are liable to be mistaken for chancroid. 

No treatment is required in either of these conditions beyond 
keeping the part clean and free from accidental infection. One 
frequently sees an attack of herpes in children followed by im- 
petigo. In some individuals the recurrent attacks can be 
aborted by taking a saline purge and making frequent local 
applications of spirits of camphor, when the stinging sensations 
indicate the onset of a fresh outbreak. In herpes progenitalis 
cleanliness is of the first importance as a prophylactic, and car- 
bolized vaselin forms a suitable dressing during the attack. 

HERPES ZOSTER 

Herpes zoster is the cutaneous manifestation of a neuritis of 
the sensory nerves of the skin. It involves the whole nerve in- 
cluding the root ganglion, and in many respects closely resembles 
an infectious disease, one attack generally protecting the in- 
dividual for life. It is analogous to anterior poliomyelitis, the 
sensory nerve roots suffering instead of the motor. The onset 
occurs with neuralgic pain in the affected nerve area accompanied 
by more or less general malaise. On about the third or fourth 
day small vesicles appear in groups at points corresponding to 
the cutaneous distribution of the nerve, and during the next fe*w 
days these vesicles continue to increase in size and often coalesce. 
They contain clear serum, occasionally tinged more or less 
deeply with blood, and show no tendency to rupture. The 



HERPES ZOSTER 



87 




Herpes zoster. Severe type, the back being involved to the same extent. 



S8 



COMMON DISEASES OF THE SKIN 




Herpes zoster. This case was suggestive of herpes simplex, but the presence of 
other groups of vesicles associated with neuralgic pain determined the diagnosis. 



HERPES ZOSTER 



89 




50 COMMON DISEASES OF THE SKIN 




Herpes zoster. Disease involving the supra-orbital nerve. 



HERPES ZOSTER 



91 



neuralgic pain may subside with the appearance of the eruption, 
but more often it persists, and it may increase in severity. It 
varies much in intensity, has periodic exacerbations Kke neur- 
algic pain generally, and is not in any way proportionate to the 
extent of the eruption. After about a week, if unruptured, the 
contents of the vesicles dry and form yellowish crusts which 



1 <3|^%^.i . 




A;^ 


P' 




f 



Herpes zoster. Ulceration following an attack which also involved the cornea. 



later drop off without leaving any scar ; though occasionally 
the disease involves the deeper tissues, leading to destructive 
ulceration, a longer period of healing, and the ultimate produc- 
tion of cicatrices. This very severe form of the disease is more 
frequently seen when the cranial nerves are involved, and when 
the supra-orbital is affected ulceration of the cornea is often 



92 COMMON DISEASES OF THE SKIN 

present. The disease is almost invariably unilateral, though bi- 
lateral instances are sometimes seen. 

The diagnosis rarely offers any difficulty. The definite dis- 
tribution of the eruption, corresponding to one or more of the 
cutaneous nerves, together with the herpetic character of the 
lesions, is seen in no other disease. When the groups of vesicles 
are so few in number and so small that their relation to the dis- 
tribution of one of the cutaneous nerves is not evident, a history 
of neuralgic pain in the area determines their character. 

As the disease runs a definite course, treatment of the eruption 
is not necessary, unless its situation exposes it to injury or it is 
of the severe ulcerative t\^e. Protection can be afforded by 
painting with flexile collodion, but this should be done early in 
the disease, as it only does harm if the vesicles have already be- 
come infected. The pain requires to be relieved and is often 
severe enough to demand morphia hypodermically. 

ICHTHYOSIS 

Ichthyosis simplex and Xeroderma are two degrees of an ab- 
normal condition of the skin which is congenital in origin. In 
Xeroderma the skin is dry, rough, and harsh, owing to thickening 
of the corneal layer, which remains adherent instead of exfoHat- 
ing on the surface as rapidly as it is produced from beneath. 
Moderate degrees of this condition are extremely common and 
associated with diminished activity of the sweat glands, per- 
sons who never perspire noticeably belonging to this class. Ich- 
thyosis simplex is a more marked example of the same disease, 
the thickening of the skin being so marked that the natural lines 
of cleavage are accentuated and the fissures and creases stand 
out in bold relief. Individuals with this condition form the 
*' alligator skin " attractions of the itinerant shows. Along 
with the discomfort due to a dry skin and its unsighthness, a 
xerodermatous individual is more susceptible to ordinary irri- 
tating influences, especially in cold weather, and persons suffer- 
ing from it are unduly susceptible to chapping and eczema. 

There is a strong hereditary tendency and commonly more 
than one member of a family is affected. 



ICHTHYOSIS 



93 




Ichthyosis simplex. Boy, aged 



94 



COMMON DISEASES OF THE SKIN 




Ichthyosis simplex. Showing detail of the upper arm, three-quarters life size. 

Same subject. 



IMPETIGO^ CONTAGIOSA 



95 




Impetigo contagiosa. 



96 



COMMON DISEASES OF THE SKIN 



^^^^^^F^^l 


"i^H 


t^^^^mss^^iZf^gs-.^ 




£ft" 


^S 



Impetigo contagiosa. This type with numerous small lesions over the face is not 
uncommon in adults. It responds quickly to treatment. 



IMPETIGO CONTAGIOSA 



97 




Impetigo contagiosa. Showing the circinate type, liable to be confused with 

ringworm. 



98 COMMON DISEASES OF THE SKIN 




Impetigo contagiosa. Circinate type here afEecting the lower part of both sides of 

the face. 



IMPETIGO CONTAGIOSA 



99 



Treatment in mild cases does much to ameliorate the condi- 
tion, but is useless in cases of ichthyosis. Hot baths with the 
free use of green soap and scrubbing, followed by an inunction, 
of cocoa butter or any mild oily application will keep the skin 
soft. Where only the upper arms and thighs are involved we 
have found the prolonged use of strong brine baths of value. 

IMPETIGO CONTAGIOSA 

Impetigo contagiosa is a localized infection of the skin produc- 
ing vesicles or pustules, which are auto-inoculable and conta- 
gious. The disease begins with the development of one or more 
vesicles, like herpes, containing a serous fluid which later may 




Impetigo contagiosa. Typical case, crusts looking as if they had been stuck on 

the skin. 



lOO 



COMMON DISEASES OF THE SKIN 



become purulent or sero-purulent, rupture, and form yellowish 
or greyish-white crusts. There is little or no inflammatory areola 
surrounding the lesions, which often have the appearance in the 
crusted stage of being attached to healthy skin. The first lesions 
are usually about the face or hands, where a scratch or slight 
injury determines their site, but later they may develop all over 




Impetigo contagiosa- Lesions show a tendency towards the ringed form. 

the body, being most numerous on those parts most readily 
accessible to the hands. Children are much more susceptible to 
the disease than adults and frequently acquire it by contact, it be- 
ing quite common to see several members of one family with it at 
the same time. Besides the common types of the disease there is 
one occasionally seen in which the lesions assume a circinate or 
ring form. 



IMPETIGO CONTAGIOSA 



lOI 



The diagnosis is not difficult, the occurrence of groups of 
vesicles or pustules, with little or no surrounding inflammation, 
being quite distinctive. Where the number of individual spots 
is large and they are all nearly of the same size, it may resemble 
varicella. The distribution of the eruption will help to separate 
them, impetigo being confined to those parts of the body within 




Impetigo contagiosa. 



Shows a very profuse eruption which appeared first on the 
upper lip. 



reach of the hands, while varicella is more evenly distributed 
and lesions are seen also on the mucous membranes. It is often 
impossible to decide between herpes simplex and impetigo in 
lesions seen about the mouth in children ; many, originally her- 
petic in origin, become infected and give rise to a crop of impetigo 
lesions while the initial sore is still present. 



IC2 



COMMON DISEASES OF THE SKIN 




KERATOSIS PILARIS 103 

Treatment is most satisfactory and a cure is readily effected. 
Before applications are made, old crusts should be softened with 
oil or warm water and removed, and vesicles and pustules broken 
and the contents wiped away ; unguentum hydrarg\Ti ammoni- 
ati is then smeared over the denuded surface several times a day. 
If new lesions are treated in a similar manner as soon as they 
appear, a cure can be obtained in a week or ten days. In chil- 
dren under two years of age the full strength of the ointment is 
unsafe and it requires to be diluted one-half. 

KELOID 

Keloid is an exuberant growth of cicatricial tissue usually 
appearing in the scars resulting from surgical operations, burns, 
etc., but occasionally arising without any major injury, sufficient 
to produce cicatrices, having preceded it. The growth is of a dull 
red colour, forms irregular welts and nodules, is extremely disfig- 
uring, and may extend wide of the original injury. Some individ- 
uals show a strong tendency to the production of keloid after 
wounds of any description and often there is a family or hered- 
itary vulnerabihty. When the growth is Hnear in shape follow- 
ing the Hne of a surgical incision, in many cases as the tissue 
contracts it diminishes so considerably in size as ultimately to 
become scarcely noticeable. 

Removal of the grow^th by surgical means is usually followed 
by its reappearance in a more prominent form, even when every 
precaution is taken to allay irritation in the healing wound. We 
have had excellent results from the use of Hquid air, taking great 
care to limit the freezing to the actual growth and only attacking 
small portions at a time. 

KERATOSIS PILARIS 

Keratosis pilaris belongs to the class of hypertrophies, the 
overgrowth being Hmited to the orifices of the pilosebaceous 
ducts. Though it does not occur until some time after birth, it 
is probably not inflammatory, but due to some congenital defect 



I04 



COMMON DISEASES OF THE SKIN 




LICHEN PLANUS 105 

in which the normal exfoliation of the horny cells does not take 
place and they remain adherent to the mouths of the hair fol- 
licles, forming small horny excrescences and giving the skin the 
feel of a nutmeg grater. A slight degree of this condition is 
extremely common on the extensor surfaces of the upper arms 
and thighs, but occasionally the condition is very marked and 
seen all over the body except the face, hands, and feet. In these 
severe cases the small hard masses at the mouths of the follicles 
often become black in colour and occasionally seal the orifices of 
the hair ducts, causing the hair to curl up in the upper part of 
the follicle and cause slight irritation, evidenced by the forma- 
tion of a small, red, inflammatory papule. The condition re- 
quires to be distinguished from ichthyosis simplex and xeroderma, 
where the w^hole of the skin and not only that at the mouths of 
the follicles is involved. The horny masses can be softened by 
an ointment containing 15 grains of salicyKc acid to the ounce 
of vaseline, and warm baths with plenty of soap gets rid of them. 
The improvement, however, is only temporary and the treat- 
ment requires to be repeated at short intervals to keep the skin 
soft. 

LICHEN PLANUS 

Lichen planus is a chronic, inflammatory disease of the skin 
in which the characteristic lesion is a smooth, flat-topped, angu- 
lar papule of a deep red to a reddish-purple colour. The angular 
papules are arranged in groups and tend to merge, as they in- 
crease in size, into flat plaques, which in old lesions are covered 
with fine, grey scales. WTien seen in oblique illumination, the 
smooth, shiny surface of the papules reflects the light Hke a 
mirror. The disease usually appears first on the wrists and thighs 
and may remain limited to these regions but often it spreads 
widely to finally cover almost the whole surface of the body. 
There is but little tendency to spontaneous cure and many cases 
last indefinitely, showing but little change. Occasionally the 
papules increase in size to such an extent that they become wart- 
like growths, a form of the disease known as Lichen planus hy- 
pertrophicus, commonly seen on the lower legs only. Pigmen- 



io6 COMMON DISEASES OF THE SKIN 




Lichen, planus. Early stage with discrete papules. 



LICHEX PLANUS 



107 








m 
^ 




Lichen planus. Detail of the last picture, three-quarters life size. Note the angu- 
lar shape of the papules, the flat tops of which have reflected the light in the 
centre of the picture. 



io8 



COMMON DISEASES OF THE SKIN 




LICHEN PLANUS 



109 




no COMMON DISEASES OF THE SKIN 

tation of a variable degree is always present and remains long 
after the disappearance of the active lesions. Subjectively, the 
disease may cause no symptoms, but in. the majority it gives rise 
to the most intense itching, and attempts to relieve this by 
scratching often result in altering the appearance of the eruption, 
excoriations, blood crusts, and infected sores being seen in addi- 
tion to the lesions already described. 

The diagnosis in cases of recent development, where one can 
see the shiny angular papules almost purple in colour, is not diffi- 
cult. Old chronic cases somewhat resemble psoriasis, but a 
careful inspection will reveal the characteristic papules some- 
where, and the scaliness is never so profuse as in psoriasis. A 
secondary s>^hilide resembling lichen planus, similarly, will 
only cause confusion if dependence is placed upon the appear- 
ance of the disease as a whole, rather than upon the character 
of the individual lesions. 

For internal treatment, arsenic pushed to the limit of toler- 
ance has long been regarded as the best remedy. It should al- 
ways be given a thorough trial by persisting in its administration 
for some weeks, using either arsenious acid in pill form or Fowler's 
solution. Of the two we prefer the latter, liquor arsenicalis, 
because of the ease with which the dose can be increased from 
day to day. A mixture containing equal parts of liquor arseni- 
calis and compound tincture of cardamoms is given the patient, 
with directions to take five drops after meals in water the first 
day, and to increase the dose one drop each succeeding day until 
the Hmit of tolerance, evidenced by nausea, suffusion about the 
eyes, etc., is reached, when the dose is reduced to five minims 
again and then gradually increased in the same manner. If 
arsenic fails to influence the disease, mercury should be tried, and 
grey powder in the form of Hutchison's pill (hydrargyrum cum 
creta, one grain, with pulveris ipecac compound, one-fifth grain) 
has proved very serviceable in our experience. Most persons 
can take from three to six pills daily without untoward effects, 
provided special care is taken of the gums and teeth. Locally an 
attempt should be made to control the itching, and a lotion con- 
taining one or two drachms of liquor carbonis detergens to the 



LICHEN PLANUS 



III 




112 



COMMON DISEASES OF THE SKIN 




Lichen planus. Showing the general distribution with marked pigmentation in 

severe case. 



LUPUS ERYTHEMATOSUS 



113 



pint of water can be used freely without ill effects, but unfor- 
tunately its sedative power is of short duration. 



LUPUS ERYTHEMATOSUS 

Lupus erythematosus is a small-celled infiltration of the skin 
tending to produce induration and atrophy and, rarely, slight 
hypertrophy. Its common situation is about the head and 







Lupus erythematosus. Showing the typical bats-wing or buttertly shape. 

face, especially on the upper portion of the cheeks and across 
the bridge of the nose, which has given rise to the name of But- 
terfly or Bats-wing lupus. It occasions no constitutional or 
subjective symptoms and is seen in early adult or middle life. 
The patches of disease are first noticeable as reddened, indurated 



114 



COMMON DISEASES OF THE SKIN 



areas with a slightly raised, sharply defined border and showing 
a few firmly adherent greyish scales, especially in the central 
portion. The disease slowly extends at the periphery, often 
taking years to reach the size of a fifty-cent piece, while the 
central portion either remains active or healing takes place with 
the formation of thin, pliable cicatricial tissue, almost indistin- 




Lupus erythematosus. Showing unilateral disease. This patient returned to the 
clinic after two years, when the area involved had increased about one-third in 
size. 

guishable from normal skin. While at first there is commonly 
more than one focus of disease, these may come to form a single 
patch by coalescence. On the face and head the disease is 
usually more or less symmetrical, the common situations on 
the scalp being back of the ears and at the nape of the neck; 
rarely other portions of the body are attacked, but in such cases 



LUPUS ERYTHEMATOSUS 



II! 




Lupus erythematosus. Showing cicatricial tissue at the left, following liquid air 
treatment, which ultimately arrested its progress entirely. 



ii6 COMMON DISEASES OF THE SKIN 




Lupus erythematosus. Case occurring at the unusual age of 12 years. 



LUPUS ERYTHEMATOSUS 



117 




Lupus erythematosus. Unusual case, symmetrical in distribution but starting from 
twenty or more different foci which later coalesced. 



ii8 COMMON DISEASES OF THE SKIN 

lesions are also found on the head. Besides the common form 
already described there is a hypertrophic form with the forma- 
tion of nodules, and a disseminated form, both of which are 
rare. 

The diagnosis is suggested at a glance in the bats-wing type 
of the disease. In other cases the age of the patient, the sharply 
defined bor/lers of the diseased areas with their slow growth, 
absence of ulceration, and atrophic centres are depended upon 
to determine their nature. Lupus vulgaris and an ulcerating 
tertiary syphilide are the only diseases Hkely to be confused 
with it. Lupus vulgaris shows, in place of the firm smooth 
border, nodules of soft tissue and much greater destruction of 
the underlying parts with thick dense scars ; and it is a disease 
commencing much earlier in life. Tertiary syphilis may closely 
resemble lupus erythematosus, but in such cases, provided no 
history is obtainable as a help, the rate of progress will decide 
between them. A syphihtic lesion will cover as much surface in 
a month as lupus will in a year. 

Untreated, the disease lasts indefinitely ; even with persistent 
treatment it is most difficult to cure. Acting on the supposition, 
as yet unproved, that it is a form of tuberculous infection, the 
general well-being of the patient should always receive attention, 
and general tonics, cod liver oil, and hygienic measures be pre- 
scribed, if this is found below par. Locally, nothing in our experi- 
ence can compare with freezing by liquid air. It is applied with 
swabs of absorbent cotton on wooden holders, as a metal applicator 
makes too good a conductor for the intense cold. A fairly large 
swab dipped in the air is brushed backwards and forwards 
over the part to be treated without exercising much pressure 
until the surface is frozen white to about the thickness of stiff 
parchment, as too much pressure results in deeper freezing and 
the production of unsightly scars. There is usually only slight 
reaction but occasionally blisters will form. Within a couple 
of weeks the effect produced can be estimated and the applica- 
tions repeated until the disease is eradicated. In large areas the 
advancing margin should be attacked first. Carbon dioxide 
snow can be used in a similar manner but it is not as easy of 



LUPUS ERYTHEMATOSUS 119 




Lupus erythematosus. Showing rather unusual shape of the area. 



I20 



COMMON DISEASES OF THE SKIN 




Lupus erythematosus. Showing the smooth white cicatrix following treatment by- 
liquid air. Several small portions on the nose still show active disease. 



MILIARIA 121 

manipulation. Failing this method, mild caustic applications 
can be ma,de with equal parts of carbohc acid and glycerine 
painted on once a day, or a lotion composed of resorcin i|-, zinc 
sulphate and potassium sulphuret aa 2^ drachms, with water to 
make up 6 ounces, can be used in a similar way. Scrubbing the 
part with spirits of green soap (sapo viridis 2 parts, alcohol i part) 
is a time-honoured remedy. SaHcylic acid in the form of an oint- 
ment or dissolved in collodion, 20 to 60 grains to the ounce, also 
answers well. In making use of these remedies the frequency 
of appHcation must be governed by the amount of inflammatory 
reaction they induce. Exposure to the Roentgen rays has not 
devorp of much value in our experience. 

MILIARIA 

Miliaria, commonly known as Prickly Heat or Flannel Rash, 
is an acute inflammatory disease produced by excessive sweating. 
It is met with at any time of year, but is more commonly seen in 
the summer time in those who are overclad, and at all times in 
those whose occupation exposes them to excessive heat. Children 
and young infants form a large proportion of the cases, as they 
perspire more readily than adults. 

The lesions consist of small, bright red papules or papulo- 
vesicles corresponding to the orifices of the sudiparous ducts. 
On its first appearance the inflammation is Hmited to the mouths 
of the ducts, and the intervening skin is unaffected, but it 
usually extends and renders the whole surface of a uniform, red 
colour, on which the papules stand out. The eruption usually 
covers a large part of the surface of the body but is apt to be more 
marked on the front and back of the upper part of the trunk. It 
lasts from a few days to a couple of weeks, and produces no symp- 
toms but a sense of burning or tinghng. 

The diagnosis is usually suggested by the conditions under 
which it occurs. In children it may at times give rise to a 
suspicion of scarlet fever, but the absence of the other symptoms, 
especially of the characteristic sore throat, will clear up the point. 
Papular eczema, unhke miharia, is extremely itchy, and rarely 
covers a large surface ; moreover, it develops more slowly. 



12 2 COMMON DISEASES OF THE SKIN 




Miliaria. Area between the shoulders spotted with tiny red papules at the mouths 

of the sweat ducts. 



MILIARIA 



123 




124 



COMMON DISEASES OF THE SKIN 




MILIARIA CRYSTALLINA 



125 




Miliaria crystallina. Sudamina on the abdomen . of a case of typhoid fever, third 

week of the disease. 



i26> COMMON DISEASES OF THE SKIN 

Treatment is rarely necessary. Cooling lotions, such as liquor 
plumbi evaporans, or a dusting powder containing one part of 
salicylic acid to fifty of boric acid, may be used. The patient's 
attention should be drawn to the cause, so that further attacks 
may be avoided. 

MILIARIA CRYSTALLINA 

Miliaria crystallina, or Sudamina, is a non-inflammatory affec- 
tion of the sweat ducts in which the perspiration collects in small, 
thin-walled vesicles looking like drops of water. It is commonly 
seen in febrile diseases in which there are periods of profuse 
sweating alternating with a dry skin, such as acute rheumatism 
and typhoid fever, where it is most frequently found on the ab- 
domen and front of the thorax. It occasions no discomfort and 
requires no treatment. 

; MILIUM 

Milium is a non-inflammatory, small, cyst-like collection of 
sebaceous material which occurs on the face and especially about 
the eyes in adults. The lesions are pinhead in size, white or 
yellowish in colour and occasion no symptoms, though their 
removal is often demanded for the cosmetic effect. This can be 
easily accomphshed by puncturing the skin over the small growths 
with a needle and expressing the contents with a comedo ex- 
tractor. 

N^VUS 

Naevus, or Mole, is a benign new growth of the skin and its 
appendages or of the blood vessels and is usually congenital in 
origin. Naevus pigmentosus is a circumscribed increase in the 
cutaneous pigment occurring either in the otherwise normal 
skin, or associated with an overgrowth of the epithelium, which 
produces a wart-like mass, Naevus verrucosus. The pigmented 
smooth form is quite common and may be limited to a few small 
stains, or there may be hundreds scattered over the body. In 



MILIUM 



127 




Milium. The tiny white tumours can be seen, two near the eye and several on the 

cheek. 



128 



COMMON DISEASES OF THE SKIN 




Naevus. Form Pigmentosus et Pilosus, deep brown in colour and covered with 

coarse hairs. 



N.EVUS 



129 



• 






.^SSfSBi 






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IP 

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N 


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Naevus. 



Vascularis et Pigmentosus. The stain was brown in colour but pressure 
showed considerable vascularity as well. 



I30 



COMMON DISEASES OF THE SKIN 



many cases associated with increased pigment, and in a few with- 
out any alteration in colour, there is a copious growth of coarse 
hair, Naevus pilosus. Naevus vascularis is an aberrant growth 
of vascular tissue, consisting either of dilated capillaries in the 
skin, giving to the part a deep red or purplish colour, the 
" port wine stain" ; or of a collection of dilated and large blood 




Naevus. Vascularis, port wine stain. 



vessels producing tumours of various sizes from a pea to half an 
orange, many of them with an uneven nodular surface. The 
vascular nature of these growths is readily demonstrated by the 
ease with which they are emptied of their contents by pressure 
made with a microscope slide over them ; but in some cases, 
especially in the port wine stains, there is found also an increase 
in pigment associated with the increased vascularity. These 



N^VUS ■ 131 

naevi are much more common about the head and face and mod- 
erate degrees are seen in a large percentage of infants at birth, 
the favourite situations being about the root of the nose and the 
margins of the hair in the occipital region. They are of a slightly 
deeper colour than the surrounding skin, becoming bright or dark 
red when the child cries or strains, and though they rarely last 




Naevus. Pigmentosus. The spots were almost black in colour and were distributed 
also over the front of the trunk. 



more than a few months, and gradually fade out, occasionally the 
colour deepens and they increase in size. The raised tumour 
forms never disappear spontaneously and usually increase in 
size. Acquired, localized enlargement of blood vessels seen in 
adult life as well as among the young are known as Telangiectases. 



13- 



COMMON DISEASES OF THE SKIN 



They begin as small, round, purplish red, slightly raised spots 
often with dilated blood vessels running into them like the 
spokes of a wheel, the " spider naevi," and they are commonly 
associated with some systemic disease. 

The treatment of port wine stains, especially if they are large 
or are pigmented as well as vascular, is most unsatisfactory, 




Naevus. Vascularis. The naevi formed quite prominent tumours over both eyes, 
involving the upper hds. 



though attempts have been made to remove the disfigurement 
by X-rays, electrolysis, freezing by carbon dioxide or liquid 
air, and radium. The smaller forms of vascular tumours are 
successfully dealt with by freezing the surface with Hquid air 
or carbon dioxide, the resulting scar tissue in the course of a 
year or eighteen months contracting sufficiently to obUterate 



PEDICULOSIS 



133 



the blood vessels underneath, but the treatment should be begun 
as early as possible in order to forestall growth. The larger 
tumours should be excised by the surgeon, as in many of them 
the blood supply comes from a large vessel. 




Naevus. Vascularis. Both sides of the lower part of the face and the chin includ- 
ing the lower lip were involved. After a year's treatment with liquid air the 
larger part of the naevus was obliterated by the cicatrices as seen. 



PEDICULOSIS 

Three species of lice are parasitic on the human body. Pedi- 
culus capitis, the head louse, is mostly confined to the hair of 
the scalp but occasionally invades the eyebrows. The female 
attaches her eggs (nits) to the hair close to the scalp by a glue- 
like substance, which resists the action of soap and water and 
makes ordinary washing ineffectual. The young hatch out in a 



134 COMMON DISEASES OF THE SKIN 

couple of days and the small bell-shaped nits remain indefi- 
nitely as empty shells, looking like small particles of dandniflf. 
As the hair grows and the empty nit is carried farther from the 
surface of the scalp, new ones are added, until it is often possible 
to count as many as a dozen or more on one hair, and thus the 
duration of the disease may be computed by the number of the 
nits and the distance of the outermost one from the head. 
Itching of considerable degree is caused by the attacks of the 
pediculi on the skin, and though the lesions which the insect is 
capable of producing are not severe enough to cause any\dsible 
break in the skin, the injuries made by the nails in scratching, and 
accidental infection of these, leads to considerable enlargement 
of the suboccipital and occalsionally of more remote glands in the 
neck. The pedicuH are most numerous in the hair of the occipital 
region and are easily seen, especially in children, who are the 
most frequent sufferers from the disease, though no age is exempt. 

As a destructive agent to both the lice and the Hving ova, 
nothing is better than kerosene oil and, as it also is a solvent of 
the chitinous substance which fastens the nits to the hair, it aids 
in their removal. The hair should be thoroughly soaked in the 
oil for twelve hours and then washed in warm water with plenty 
of soap. The oil rarely causes any irritation but it is better to 
dilute it one-half with oHve oil for young children. After the 
lice are destroyed, unguentum hydrargyri ammonia tum serves 
as a good application to any infected sores which may be present. 

The body louse, pediculus corporis or vestimentorum, has its 
habitat on the trunk and rarely travels to the head or extremities, 
unless present in very large numbers. The back between the 
shoulders is its favourite home on account of the warmth and 
freedom from disturbance. The ova are attached to the hairs 
of the clothing and are found, along with the parasite itself, by 
examining the inside of the undershirt, especially in the seams 
and rolled-over edges of the cloth. Itching is the only symptom, 
and often the only e\ddence of the presence of the Hce is the 
scratch marks inflicted by the finger nails in the attempt to reheve 
it, though in long standing cases of the disease pigmentation in 
the form of small, irregular, brown patches does occur. 



PEDICULOSIS 



135 




Pediculosis. Capitis, showing enormous numbers of nits on the hair, which had 
been cut away by the mother at one point to get at an infected sore. 



136 COMMON DISEASES OF THE SKIN 

The diagnosis is only in doubt when the patient has donned 
clean underclothing just before consulting the physician, making 
it difficult to obtain evidences of the parasite. Scabies can 
generally be excluded as it does not affect the back until it has 
been present for some months on the arms and anterior surface 
of the body and has covered a large extent of surface. 

Sulphur ointment destroys the pediculi, but unless the clothing 
is changed, or the vermin and eggs present on it killed, its use is 
only palliative. All clothing that will bear it should be boiled 
and woolen garments exposed to dry heat by baking in a hot 
oven. 

The crab louse, pediculus pubis, lives in the hair about the 
genitals, sometimes wandering to the axillary hair and eyebrows 
and occasionally to the scalp. As its name implies, this louse is 
provided with two prehensile claws resembling those of a crab 
by means of which it clings to the pubic hair and is very diffi- 
cult to dislodge. The ova are attached to the hairs of the 
pubic region. Infection occurs by contact and is commonly 
associated with venereal disease for obvious reasons. It gives 
rise to intolerable itching. Blue ointment, unguentum hydrar- 
gyri, is the time honoured remedy, and is most effectual, 
though in some individuals it produces an acute dermatitis. 

PITYRIASIS ROSEA 

Pityriasis rosea is an acute inflammatory disease having a 
fairly constant distribution and running a definite course. It 
begins by the appearance of a single lesion somewhere on the 
trunk or adjacent portions of the limbs, round or oval in shape, 
the size of a ten-cent piece or larger, of a pinkish colour at the 
margins and yellowish or white in the centre, where it is flaked 
over with small furfuraceous scales. After an interval of a week 
or more, that portion of the body which is covered by an under- 
shirt becomes studded with numerous similar lesions, varying in 
size but seldom equalhng the original one, and between these 
larger spots are many small macules or papules which differ 
from them in not showing any scales. The disease runs a definite 



PITYRIASIS ROSEA 



137 




Pityriasis rosea. Shows the distribution of the large and small lesions over the 

back. 



138 COMMON DISEASES OF THE SKIN 




Pityriasis rosea. Shows the detail of the larger lesions only. 



PITYRIASIS ROSEA 



139 




Pityriasis rosea. Shows the primary lesion on the right thigh and a commencing 

general eruption. 



140 



COMMON DISEASES OF THE SKIN 




Pityriasis rosea. Detail of the eruption, three-quarters life size. The prominent 
hair follicles, cutis anserina or " goose flesh," which the camera has caught is 
not part of the disease. 



PRURITUS 141 

course of from three weeks to three months and gives rise to no 
symptoms except occasional shght itching. 

The diagnosis is made from the distribution of the disease, the 
history of its rapid development, following at an interval after 
the appearance of the initial lesion, and the absence of symptoms. 
When seen early the single spot may be mistaken for ringworm 
which it closely resembles, but failure to find the ringworm fungus 
in the scales will enable one to eliminate it. An early secondary 
syphilide can be excluded by the absence of the other signs of 
this disease and by the Kmited distribution. 

Treatment is hardly required except as a placebo, though anti- 
pruritic lotions are occasionally demanded. Jamieson believes 
in the possibility of shortening the duration of the disease by 
the use of potassium permanganate baths and the local appHca- 
tion of an ointment of saHcylic acid, 15 to 20 grains to the ounce. 

PRURITUS 

Pruritus, or Itching, is a sensation common to a great many 
diseases of the skin and needs no definition. Pruritus, however, 
for which there is no apparent cutaneous cause and no evident 
skin lesions except those due to traumatism in the effort to obtain 
relief by scratching, has been included as a disease in itself. 
Two principal forms can be recognized, pruritus senilis, one of the 
disabiHties of old age, and pruritus hiemalis or winter itch. 
Pruritus senilis, an incontrollable itching, which disturbs the 
rest of old people, is of unknown origin, though it has been 
attributed to loss of the subcutaneous fat, which occurs at that 
time of life. The itching occurs on any part of the body, is 
most intense at night, and except for the consequent loss of rest, 
occasions no other symptoms. It is most refractory to treatment. 
Antipruritic lotions ease the suft'erer for only a short time and 
need frequent repetition. We have found one or two drachms 
of liquor carbonis detergens to a pint of water as effectual as 
any. A mustard paste applied to the nape of the neck for a few 
minutes will often procure a night's sleep, but treatment of 
this kind can only be used occasionally. There is the same 
objection to making use of strong sleeping draughts. 



142 COMMON DISEASES OF THE SKIN 

In Pruritus hiemalis the itching is most severe just after re- 
moving the clothes at bedtime. It is more common in cold 
climates and is thought to be due to the clinging character of 
the heavy woolen underwear worn in winter. When the itch- 
ing affects only the legs, it is sometimes possible to relieve it by 
the simple expedient of pulling the tight-fitting woolen drawers 
up to the knees and then pulling them down again, when the 
garment is put on in the morning. As the hairs of the legs are 
coarse and lie naturally with the points directed downwards this 
ensures their lying in that position during the day. Thin cotton 
or mushn garments worn underneath woolen ones often relieve 
this form of pruritus, as the smooth cotton does not afford a sur- 
face to which the lanugo hairs can cling. Antipruritic lotions 
bring relief and should be freely used, and the patient encouraged 
not to scratch. Scratching soon develops into a habit, which 
when repeatedly indulged, increases the irritability of the skin. 

PSORIASIS 

Psoriasis is a chronic inflammatory disease of the skin char- 
acterized by the formation of sHghtly raised, indurated patches 
of varying shape and size covered with dry scales. The initial 
lesion is a small papule slightly deeper in colour than the sur-' 
rounding skin, which, as it increases in size, develops a covering 
of fine, silvery white, closely adherent scales; and the removal 
of these with a curette or the finger nail discloses a bright red 
surface showing one or more tiny bleeding points. As the 
patches increase in size they may retain a round or oval shape, 
become irregular in their outlines, or form ring-shaped or gyrate 
figures, the last two forms resulting from involution of the centre 
of the patch keeping pace with the extension of its borders. It 
was formerly the custom to describe many varieties of the disease 
based on the predominating shape of the lesions ; punctata, 
guttata, and nummularis were round lesions equal in size to a 
pinhead, a drop, or a coin ; and circinata and gyrata were 
the ring-shaped and wavy-outlined forms already mentioned. 
Roughly, one can divide the disease into acute and chronic groups,- 



PSORIASIS 



145 




Psoriasis. Variety Punctata, lesions very small. 



144 



COMMON DISEASES OF THE SKIN 




Psoriasis. Guttata. 



PSORIASIS 



145 




Psoriasis. Nummularis, on the body, diffuse on the arms. 



146 COMMON DISEASES OF THE SKIN 




Psoriasis. Gyrata. 



PSORIASIS 



147 




Psoriasis. Chronic, the two areas shown persisted for years. 



148 COMMON DISEASES OF THE SKIN 




Psoriasis. Acute case in child of nine. It had existed a month when the photo 

was taken. 



PSORIASIS 149 

classing as acute those in which there is progressive increase in 
the size of the lesions or rapid development of new ones, and 
chronic those where the lesions tend to remain the same size for 
months or years. In the more acute forms the patches are seen 
all over the body, and may change in size and shape from week 
to week, new lesions appearing as the older ones disappear. The 
chronic form on the other hand shows a marked preference for 
the extensor surfaces about the elbows and knees and for the 
scalp. While the disease may last indefinitely, it often im- 
proves greatly or disappears entirely with the changes of the sea- 
sons, many cases getting well or nearly well in spring or summer 
to recur with the autumn or winter, others having recrudesences 
in summer and remissions in winter. In the majority, however, 
the patches do not entirely disappear from the knees, elbows, and 
scalp, when the remissions occur. Psoriasis is seen at all ages 
with the exception of early childhood and has a well marked 
hereditary or family tendency, it being quite common to find it 
in several generations and in more than one member of a family. 
It rarely produces any subjective symptoms, though occasionally 
itching is complained of, and it does not influence the general 
health. 

The diagnosis is readily made in the great majority of cases 
from the presence of the silvery white scales, and the history 
that the eruption has always presented the same features. Con- 
firmatory evidence can be obtained by scraping off one of the 
smaller lesions and noting the tiny bleeding point on the raw 
surface underneath. In old chronic cases, especially in persons 
who take good care of their skin, the scaly nature of the disease 
may not be at once evident, but the scales can invariably 
be demonstrated by drawing the back of the finger nail across 
the spots. When the scalp is the only part affected the disease 
may resemble seborrhoea, but can be distinguished from it by 
the fact that the patches of psoriasis are multiple and have well- 
defined margins, while that of seborrhoea is single, as a rule 
central, and shades off gradually into the normal skin. 

Arsenic has long held first place in the internal treatment of 
psoriasis. Its administration should begin with small doses 



ISO 



COMMON DISEASES OF THE SKIN 




PSORIASIS 



^51 




15^ 



COMMON DISEASES OF THE SKIN 




Psoriasis. Large patches on the leg below the knee. 



PSORIASIS 



153 




154 



COMMON DISEASES OF THE SKIN 




PSORIASIS 



155 



slightly increased daily until the patient's tolerance is deter- 
mined, when it is either withheld temporarily or the course is 
repeated, beginning with the minimum dose as described under 
lichen planus. Salicylate of soda given in fairly full dosage has 
proved useful in our hands in rapidly developing attacks and 
especially in early life. Thyroid gland has the power in most 




Psoriasis. Circinata and gyrata in type. 



patients of rapidly clearing up the eruption, but the disease is 
apt to return after a short interval and is not influenced by it 
again to the same extent, on resuming the treatment. In obsti- 
nate cases where nothing seems to be of much use it is often 
wise to abandon specific treatment for a time and put the patient 
upon general tonics for a few weeks, when the drug which formerly 
failed may become effective. Change of air and habits, a visit 



156 COMMON DISEASES OF THE SKIN 

abroad, may cause the disappearance of the disease but are just 
as Hkely to aggravate it. 

In the local treatment the essential point is to remove the scales 
before making appHcations. A stiff nail brush with soap and 
hot water should be used to remove all that can be scrubbed off 
the scaly tops of the patches before applying the chosen remedy, 




Psoriasis. Type formerly called inveterata, where almost the whole surface of the 

bodj^ is involved. 

and the scrubbing should be repeated every day. Failure 
to get results is often due to neglect of this procedure. Chrys- 
arobin, 5 to 20 grains to the ounce of vaseline, is rubbed well 
into the denuded patches once a day, using the weaker strength 
where the surface to be covered is large, as this drug is a powerful 
irritant both to the skin and the kidneys, and when used for 



PURPURA 157 

any length of time produces an intense erythema of the skin 
surrounding the patches. Not infrequently the erythematous 
dermatitis produced by the chrysarobin is so intense as to neces- 
sitate its abandonment until the irritation has subsided. Owing 
to its staining properties, it is well to warn the patient that 
anything coming in contact with it will be dyed brown ; and it 
is our practice to have the applications made at night and thus 
allow the excess to rub off on the night clothes and bed Knen, 
using the same clothes until the treatment is discontinued. For 
the same reason the patient should be told not to apply the 
ointment to the face or scalp, but replace it with plain vaseline, 
which is an excellent solvent for removing the scales. It is 
found that when the disease is yielding to treatment elsewhere, 
it usually disappears spontaneously from the scalp. To prevent 
staining and insure a prolonged action, chrysarobin and other 
drugs are often used in the form of a gelatine varnish, which is 
painted on the spots while hot and on cooling forms a coating 
which will last for several days, but we have not found this as 
effective as a daily treatment with ointment, preceded by a 
thorough scrubbing of the parts. Next to chrysarobin in point 
of efficiency is tar used in the form of the unguentum picis, oil 
of cade, or Hquor carbonis detergens. 

PURPURA 

Purpura is a haemorrhagic disease of the skin, symptomatic 
of some general disorder, and usually associated with a patho- 
logical condition of the blood. In Purpura simplex there are no 
constitutional symptoms and the disease is evidenced only by 
the presence of small intracutaneous or subcutaneous haemor- 
rhages, which occur in large numbers and are of varying size, up 
to an inch or more in diameter. Their haemorrhagic nature is 
shown by persistence of the colour under pressure, tested by 
pressing a microscope shde or glass lens upon the skin. The 
haemorrhages frequently appear in crops and the colour often 
indicates their age ; thus recent lesions are bluish or bright blood 
colour according to the depth at w^hich they lie in the integument, 



iS8 



COMMON DISEASES OF THE SKIN 




PURPURA 



159 




Purpura. Simplex. The lesions here came out in crops, the more recent ones being 

darker in the picture 



i6o COMMON DISEASES OF THE SKIN 

and later this changes to purple, then bluish green or greenish 
yellow as they disappear. The eruption may cover the entire 
surface of the body, but the spots are more numerous on the 
extremities, especially the legs, and not infrequently are con- 
lined to these parts, the trunk escaping. The attack is com- 
mxOnly over in two weeks, but the disease is apt to recur and may 
keep on doing so at irregular intervals for months or years. The 
diagnosis gives rise to no difficulties and no special treatment 
is required. 

Purpura rheumatica, or Arthritic purpura, is associated with 
the symptoms of arthritis, rheumatic pains, and sometimes 
soreness and swelling about the joints, with more or less con- 
stitutional disturbance. The cutaneous lesions may be similar 
to those described under Purpura simplex or they may be grouped 
about the affected joints. Besides the intra- and subcutaneous 
haemorrhages, extravasations at times occur so superficially that 
they give rise to raised, fiat, wheal-like lesions. In this form of 
purpura the symptoms are often very severe and may include 
endocarditis, pericarditis, and septic angina with high fever, 
while a fatal ending is not unusual. Cases in which the extra- 
vasations of blood are unusually large and accompanied by 
haemorrhages from the mucous membranes are known as Purpura 
haemorrhagica and are indicative of some grave change in the 
composition of the blood. 

The diagnosis of these forms of purpura depends upon the 
association of the arthritic lesions with the haemorrhagic erup- 
tion. 

Treatment must be directed to dealing with a possible etio- 
logical factor and hence varies widely with the class of case. 
Salicylate of soda has been found of use in those cases likely of 
rheumatic origin, but the fact that this drug produces a haemor- 
rhagic eruption in some individuals must be kept in mind. Lo- 
cally no treatment is needed. 



PURPURA 



i6i 




Purpura. Simplex. In this case there were a very large number of very small haem- 
orrhages and no large ones. Illustration shows the upper part of thighs and 
buttocks in a child, aged five. 



l62 



COMMON DISEASES OF THE SKIN 




RINGWORM 163 

RINGWORM 

Under the heading of Ringworm we include all lesions produced 
in the skin and its appendages by the parasitic growth of a fam- 
ily of mould-like fungi, the trichophytes. The glabrous skin, 
scalp, beard, genital regions, hands, feet, and nails are all liable 
to be attacked by one or more forms of the fungus ; but, while 
some forms are found to thrive equally well in many localities, 
others will only grow under certain conditions, conditions which 
one part of the body alone furnishes. By means of micro- 
scopic examination and by their growth on various culture media, 
a large number of different species of fungi and many varieties 
have been differentiated, but for practical diagnosis and treat- 
ment the ability to recognize by means of the microscope the 
presence of some member of this large family is all that is neces- 
sary. 

Ringworm of the scalp. Tinea tonsurans, is common in chil- 
dren and rare in adults. When the skin of the scalp first be- 
comes infected with the fungus the disease shows merely as a 
small round area, slightly redder than normal and covered with 
small dry scales, but later, when the hairs are invaded, they lose 
their lustre, become dry and brittle, and bend or break off near 
the surface of the skin. This gives rise to a partially bald patch, 
circular or oval in outline, covered with a coating of fine, branny 
scales, among which are seen the stumps of the broken hairs. 
On examining one of these broken hairs with a strong lens or 
under the low power of the microscope, its extremity is seen to be 
frayed and brush-like from the separation of its fibres w^here the 
fracture has taken place. The initial patch continues to grow 
in size and new ones to appear as the spores from the first are dis- 
tributed and form new colonies, until the whole scalp may ulti- 
mately be infected. Ringworm is highly contagious and unless 
discovered early is likely to spread rapidly through a family or 
school, especially as the growth of the fungus on the skin causes 
no irritation and the disease is not discovered until the partial 
baldness draws attention to it. Occasionally, through acci- 
dental causes or through the use of unwise home remedies, pus 



1 64 COMMON DISEASES OF THE SKIN 




Ringworm. Tinea tonsurans. Typical case. 



RINGWORM 165 

infection occurs, and a condition somewhat analogous to sycosis 
is produced. The diseased area becomes raised, reddened, 
spongy, and tender to touch and exudes small drops of pus from 
the hair follicles on pressure. All the hairs, diseased and sound 
alike, become loose and soon fall or are readily extracted, leaving 
a raised, bald patch suggestive of a subcutaneous abscess, and as 
a consequence sometimes incised by mistake. This condition is 
known as Kerion. and when it does occur results in a complete 
cure of the ring^vorm but possibly in the production of perma- 
nent baldness owing to the destruction of the hair papillae. 

The diagnosis is readily made from the presence of broken 
hairs in a more or less bald patch and by microscopic examina- 
tion. Several of the diseased hairs should be extracted and 
mounted in Uquor potassii on a sHde with a cover slip. After a 
few minutes the hairs become softened and pressure on the 
coversHp will partly disintegrate them. Under the high power 
the fungus is seen either as long unbranched threads of mycelium 
or more often as chains of spores in the hair or the hair-sheath, 
which comes away with the hair when it is extracted. Favus 
of the scalp can be distinguished by its different mode of growth, 
its fungus invading the tissue of the skin and forming a sulphur 
yellow crust which on removal leaves a bleeding surface under- 
neath. Baldness only occurs from it when the disease is far 
advanced and in the process of healing, and the indi^'idual bald 
areas are small, irregular in shape, and give the scalp the appear- 
ance of moth-eaten fur. Microscopically, too. the fungus will 
be found in the yellow crusts rather than in the hairs, though the 
latter are also invaded. 

Treatment is effective only if the fungus can be destroyed by 
germicidal appKcations or by removal of the hair. Epilation. 
carefully done, if the area to be treated is small, is most satis- 
factory. Many hairs will break off level with the skin on the 
first attempt to remove them, but they can be extracted entire 
later when they have grown sufficiently to give the epilation 
forceps a hold. \Mien the area to be denuded is too large for 
manual epilation, the hair can be removed by an exposure to 
X-rays, which, if properly given, causes the hair to fall within 



i66 COMMON DISEASES OF THE SKIN 

two or three weeks. This is the most satisfactory method of 
removing the hair but it should only be undertaken by an ex- 
pert Roentgenologist, as too severe exposure results in destruc- 
tion of the hair papilla and subsequent baldness. Complete 
removal of the hair, while it carries with it most of the fungus 
which is found in the hair and hair-sheath, does not effect a cure ; 
it is necessary to employ germicidal applications as well to de- 
stroy the fungus present in the skin, and it is well to cover the 
whole scalp occasionally to prevent infection of other parts. 
Unguentum hydrargyri ammoniatum or oleatis answers very 
well. When. X-ray treatment is not available and the disease 
is too widespread for epilation, recourse must be had to local 
applications alone, but the patient should be warned that this 
method of treatment is slow and tedious, often requiring many 
months of patient care on the part of the mother or nurse. Tinc- 
ture or liniment of iodine has proved the most serviceable in 
our hands and it has one great advantage ; namely, that owing to 
its staining properties, one can judge whether one's directions 
are being carried out properly. The hair should first be evenly 
and closely cropped, using a barber's clippers, and it is then 
easy to detect any small scaly areas where the disease has al-' 
ready begun but in which the hairs are not as yet involved. 
Shaving the scalp is not wise as it increases the difficulty of de- 
tecting incipient patches. Iodine is then painted daily for five 
days on all the places showing evidences of disease, and it stains 
and destroys the superficial layer of the epidermis. On the 
sixth day the iodine is replaced by vaseline, and on the seventh 
the head is thoroughly washed and the child inspected by the 
physician, who is able with a metallic comb to remove the super- 
ficial eschar caused by the iodine, along with all the loose diseased 
hairs and scales which have become entangled in it. After 
repeating this process several times the iodine can be discon- 
tinued for a week, and the next inspection will show by the 
presence or absence of scales and broken hairs how the case is 
progressing. In isolated patches of small size, where there is 
objection to cutting the hair, the production of an artificial 
kerion by applying equal parts of olive and croton oil daily, until 



RINGWORM 



167 




i68 COMMON DISEASES OF THE SKIN 

suppuration takes place and the hairs fall or can be easily ex- 
tracted, is an alternative method of treatment. As it is difficult 
to limit the destructive effect of the croton oil it should be used 
cautiously or it may leave a bald area. 

Ringworm of the non-hairy skin, Tinea circinata, is met with in 
both childhood and adult life, but is much more common in the 




Ringworm. Tinea circinata. Two patches on the child's face, one showing two 
concentric rings, latter a rare condition. 

former. The growth of the fungus on the skin produces an 
extremely mild, superficial inflammation with the formation of 
fine scales. The disease, like all fungoid growths, tends to 
assume a ring shape, spreading outwards at the circumference 
while the centre heals, and exceptionally a second ring forms 
within the first. In an actively growing area the extending 



RINGWORM 



169 




Ringworm. Tinea barbae. Severe form in a stableman. Lesions were seen also 
on the lobes of the ears, the neck, and upper part of the thorax. 



I70 COMMON DISEASES OF THE SKIN 

border is slightly raised above the surrounding skin, sharply- 
defined, and covered with fine chaffy scales ; occasionally the 
fungus causes sufficient reaction to produce vesication. The 
number of individual lesions is usually small, and the uncovered 
parts of the body are naturally the most frequently affected. 

The nature of the disease can always be suspected by the 
ringed shape of the lesions, but a microscopic examination of the 
scales is needed to make sure of the diagnosis. A few scrapings 
mounted in liquor potassu and examined under the high power 
of the microscope disclose the characteristic myceha and chains 
of spores. 

A cure is readily effected by any mild antiseptic ; when writing 
ink was a tannate of iron it was the popular school remedy. 
Tincture of iodine is now most frequently used, but one must 
avoid its too frequent application as in many children it acts 
as a powerful irritant and may set up a severe dermatitis. One, 
or at most two, applications are quite sufficient to kill the fungus. 
Unguentum hydrargyri ammoniati smeared on several times 
a day will destroy the fungus without harming the skin. 

Ringworm of the beard, Tinea barbae, is much less common 
than the same disease in the scalp and is a much more severe 
affection. The severe form is met with mostly in stablemen 
who have the care of cattle or horses, and is due to a variety of 
the fungus obtained from these animals. The hairs become in- 
fected, but do not show the same tendency to break as in tinea 
tonsurans, and the tissues are deeply invaded by the fungus, 
producing considerable swelling with the formation of nodules 
and pustules. 

The diagnosis can only be made by a microscopical examination 
of the infected hairs. Treatment is along the same lines as in 
ringworm of the scalp, in many cases, however, soothing applica- 
tions and hot compresses must be employed to reduce the inflam- 
mation before the use of strong germicidal remedies can be in- 
stituted. When, as is sometimes the case, the beard becomes 
infected with the same variety of fungus found in the scalp, the 
disease presents the same picture as in that disease. 

Tinea unguium, or Ringworm of the nails, is probably caused 



RINGWORM 



171 



by the spores of the fungus becoming lodged in the furrow under 
the free border of the nail, and that it is not more common is 
probably due to the fact that the hard tissue of the nail makes 
it difhcult for it to secure a foothold. As the fungus grows 
in the nail tissue it renders it opaque, thickened, and brittle, and 
the free end of the nail breaks away irregularly. More than 
one finger is usually infected but seldom all of them. 

Recognition is not easy unless one suspects the cause and 
resorts to a microscopical examination of the brittle nail sub- 




Ringworm. Tinea unguium. In the middle and ring fingers the thickened nails 
which have broken off are well shown. The other fingers were not affected. 



stance, after macerating it for some time, or boiHng it in liquor 
potassii. Other diseases likely to be confounded with ringworm 
are psoriasis of the nails, always associated with psoriasis else- 
where, and syphilitic onychia. 

The disease is more difficult to treat than the other forms of 
ringworm, owing to the inaccessibility of the fungus in the 
dense nail tissue. Softening the parts with Hquor potassii or a 
strong solution of saKcylic acid enables one to scrape away the 
diseased portions of the nail, and it also destroys the fungus. 
These remedies can be conveniently used by soaking small 



X72 COMMON DISEASES OF THE SKIN 

pieces of gauze in them and then applying the pledgets over 
the nail and covering the whole with a rubber finger stall. 

Another form of Ringworm, Tinea cruris, is hard to recognize 
and occurs on the genital regions, the axillae, and the hands and 
feet. The fungus differs somewhat from the trichophyton and has 
been called the epiphyton. It is very tenacious of life and keeps 
recurring in the same locality many times after its apparent 
cure. The lesions it produces are unlike those seen in the other 
forms of this disease and resemble closely the moist varieties of 
eczema, but differ from it in having a well-defined margin. In 
the groins and axillae the disease occurs as shghtly raised areas 
covered with moist excretion, which dries in yellowish crusts 
and which re-form over and over again if removed. It has a 
sharply defined margin and extends slowly at the borders, often 
remaining practically of the same size for months at a time. 
During the summer, when the parts affected are apt to be 
bathed in perspiration, the growth is more active than in the 
winter when they are dry, but the disease may last for many 
years. When occurring on the hands or feet, the webs of the 
fingers or toes are the most frequent site, but it is quite common 
on the thickened skin of the palms and soles. Here again it 
closely resembles a chronic .vesicular eczema, beginning as 
vesicles which show little tendency to rupture, but coalesce to 
form blebs filled wit^ a sero-purulent fluid. This in time dries 
and the overhing skin desquamates, the same process being 
frequently repeated. 

The diagnosis can only be made with certainty by finding the 
fungus in the skin, but old cases of recurring eczema of the 
hands, feet, or genital regions should always be regarded with 
suspicion, especially if the disease remains limited to these 
localities. Recognition of the fungus is more difficult here 
than in other forms of invasion by this parasite. The skin over- 
lying the vesicles or the dry desquamating flakes should be boiled 
in liquor potassii for fifteen minutes and teased out with a 
needle, so that when mounted on a slide pressure on the cover- 
glass will form a thin fihn, and enable the mycelial threads of the 
fungus to be seen, 



RINGWORM 



173 




174; COMMON DISEASES OF THE SKIN 

In treatment the aim is to use germicidal remedies which at 
the same time are solvents of the skin. Salicylic acid proves 
very effective and may be used in strength up to 30 grains to the 
ounce. Sodium hyposulphite, one or two drachms to the ounce 
in a watery solution, will soften the skin and destroy the fungus. 
Balsam of Peru, painted on pure, is especially useful between 
the toes, where, from its viscid quality, it keeps moist and 
active for longer periods than most applications. 

SCABIES 

Scabies is a contagious, parasitic disease caused by the itch 
mite Acarus hominis, a small insect just large enough to be 
visible to the naked eye. The female drills a burrow in the skin 
just below the horny layer and here deposits her eggs, and these 
burrows can sometimes be seen as fine red lines, not over one- 
quarter inch in length ; but more frequently the site of a burrow 
is disclosed by the formation of a small papule or vesicle at 
each end. A needle introduced at one end of the burrow and 
pushed along it will open it up without causing bleeding, and 
if it is freshly made and contains the living parasite, she may be 
found clinging to the point of the needle. Owing to the intense 
itching caused by the disease, secondary lesions due to scratch- 
ing and pus infection predominate in the majority of cases, and 
the burrows can only be detected if carefully sought for among the 
pustules and excoriations. The extent to which secondary lesions 
develop varies widely, some individuals becoming covered with 
purulent sores, while others escape with a few scratch marks. 
The disease first makes it appearance in the majority of cases on 
the hands in the webs between the fingers, as the parasite here is 
less likely to be brushed off before it has had time to penetrate 
the skin, and spreads thence to the arms, axillae, and genitals ; 
but in time all parts of the body may become infected, the feet 
being usually the last to become involved. The disease is due 
to direct contact with an infected person in the great majority 
of cases, though the possibility of contagion through the medium 
of clothes cannot be denied. It lasts indefinitely if untreated, 



SCABIES 



175 




176 COMMON DISEASES OF THE SKIN 

and causes no symptoms apart from the itching and those due 
to secondary infection. 

The diagnosis is as a rule not difficult, though one may not be 
able to discover the acarus. Its distribution, especially the 
early involvement of the hands, a history of other similar cases 
in the persons with whom the patient comes in contact, the 
severe itching and the presence of the pairs of papules and pustules 
with a few burrows, make its recognition easy. In dirty adults 
the possibility of pediculi corporis must sometimes be considered, 
but here the bulk of the disease is between the shoulders, and the 
hands and arms are not involved ; in children urticaria may 
cause some confusion, but the history should lead to a definite 
conclusion, evidence being obtained of the absence of a source 
of contagion and of the presence at some time of the character- 
istic wheals. Children subject to urticaria who develop scabies 
must have contracted the disease from some other member of 
the family. The cases most difficult to diagnose are those 
which occur in adults who are accustomed to a daily bath and 
frequent change of underclothing, as under these conditions the 
parasites get little chance to multiply and secondary lesions are 
rarely present. Here the evidence is very slight and the real 
nature of the disease may remain unsuspected for a long time 
unless a thorough search is made for the presence of the burrows. 

Sulphur ointment will always bring about a positive cure if 
properly used. The whole surface of the body should be well 
smeared with the ointment once a day for three days, the patient 
continuing to wear the same underclothing and refraining from 
taking a bath. Within three days all the ova have hatched and 
the young perished, and on the fourth morning the patient takes 
a hot bath with plenty of soap and puts on clean underclothing. 
Itching is apt to persist for some time after the parasites have 
been killed, partly from a habit having been established and 
possibly from irritation due to the sulphur. If the patient is 
warned of this and given an antipruritic lotion, it soon sub- 
sides. 



SCABIES 



177 




178 COMMON DISEASES OF THE SKIN 

SEBGRRHCEA 

Seborrhoea, as the name implies, is an excessive flow of the 
secretion of the sebaceous glands and is not primarily an inflam- 
matory disease. The overabundant secretion may appear either 
as a dry, flaky, readily detachable, fatty scale (dandruff) or as 
moist semi-fluid oily crusts collecting on the skin. When, as is 
frequently the case, the oily crusts or scales overlie an inflamed 
surface, the condition is more correctly classed as eczema sebor- 
rhoicum, though excessive functioning of the sebaceous glands 
may have been the etiological factor producing it. Seborrhoea 
is Hmited to the scalp almost entirely, the so-called seborrhoea 
corporis, being of inflammatory origin, is a form also of eczema 
seborrhoicum. The oily form of seborrhoea is quite common in 
young infants owing to the disincUnation of many mothers to 
use soap on the scalp, where the secretion collects in yellowish, 
greasy crusts which become matted into the hair and firmly ad- 
herent, popularly known as the " milk crust." The irritation 
caused by this condition often results in a dermatitis of the skin 
of the scalp. 

Seborrhoea requires to be distinguished from psoriasis, a matter 
of some difficulty when that disease is limited to the scalp. 
In seborrhoea the scaly area is limited to a single patch, perhaps 
covering the entire scalp but sometimes only on the vertex : 
in psoriasis, on the other hand, the patches are multiple and have 
well-defined margins separated by areas of normal skin, while 
the scaliness is much more profuse. Ringworm of the scalp is 
sometimes scaly and might be mistaken for seborrhoea, were it 
not for the broken hairs which are always in evidence and which 
on microscopical examination reveal the fungus. 

The occurrence of dandruff is at times an indication that the 
individual's general health is below par, hence, where indicated, 
tonics should be prescribed. Locally, the treatment is more or 
less unsatisfactory, the best results being obtained by frequent 
washing of the head with a bland soap and thoroughly rinsing 
out the soap before drying the hair. In persons with short hair 
a^daily wash will keep down the dandruff and relieve the itching 



SYCOSIS VULGARIS 179 

which is often a symptom when the dandruff is allowed to accu- 
mulate. In women this is an impossibility on account of the 
difficulty of drying the long hair, and resort can then be had to 
lotions, though oily preparations should be avoided. The lotion 
we use contains resorcin 20 grains, acetic acid 30 minims, rectified 
spirits 2 drachms, castor oil 3 minims to the ounce of water. The 
supposed connection between seborrhoea and baldness has al- 
ways seemed to the writer unlikely, as women who suffer from 
the former equally with if not in greater proportion than men, 
are very much less commonly affected with the latter. 

SYCOSIS VULGARIS 

Sycosis vulgaris is a pustular infection of the hair follicles of 
the beard and moustache. The pus-producing organism is in- 
troduced from without, commonly by means of shaving utensils 
which have become infected from a previous case, and hence 
the common name " Barber's Itch." 

The disease begins with redness and irritation of the skin of the 
bearded region of the face, coming on a few hours after exposure . 
There is considerable soreness and some itching, followed in the 
course of a day or so by the appearance of small pustules, which 
can be seen on close examination to correspond to the orifice of 
the hair follicles, often with a hair in the centre of the pustule. 
At first the hairs are firmly fixed, but after the disease has lasted 
for some days the pus infection tends to invade the tissues more 
deeply, and the sebaceous glands and hair papillas being involved, 
the hairs fall or are readily plucked out. The infection spreads 
rapidly and from a single small area a widespread distribution 
of the disease may arise, accompanied by considerable tumefac- 
tion of the tissues. There is little tendency to healing and un- 
treated cases last indefinitely or until the whole of the bearded 
region has been invaded, though there is little disposition to 
spread to the glabrous skin, and the hair of the scalp is never 
involved. 

In the matter of diagnosis the possibility of ringworm and 
eczema of the bearded region must be considered. Many cases 



i8o 



COMMON DISEASES OF THE SKIN 




Sycosis vulgaris. Xote the hair in the centre of many pustules. 



SYPHILIS i8i 

of ringworm present an almost identical picture to sycosis, and 
reliance must be put on a microscopical examination of the hairs 
to decide between them. A pustular eczema of the beard is not 
so easy to differentiate. Stress must be laid on the absence of 
induration in sycosis as compared to eczema, and on the fact 
that eczema is rarely limited to the bearded region alone. In 
eczema one sees a reddened indurated area over which pustules 
having no special relation to the hair folhcles are distributed, in 
sycosis a diffuse pustular foUicuhtis about which there is the red 
inflammatory areola common to all pus infections. 

The treatment of old-standing cases is often difhcult owing to 
the impossibility of reaching the deeply seated pus-producing 
organisms by external applications. It is always possible how- 
ever by the use of strong germicidal remedies to prevent the 
spread of the disease, and in time the purulent folliculitis runs 
its course and dies out. In our experience nothing is so eff'ectual 
as oleate of mercury ointment used in as strong a form as the 
patient can bear, beginning with a drachm of the ungt. hydrar- 
gyri oleatis to the ounce of any simple ointment and increasing 
the strength gradually. This should be smeared over the part 
twice daily. It is most important to have the hair of the beard 
shaved daily, even though the shaving causes at first considerable 
bleeding and pain. 

SYPHILIS 

Syphilis, considered from the point of view of its cutaneous 
manifestations, is divided into three stages, the first of which 
comprises the time from the appearance of the primary lesion 
or chancre until the onset of signs of general systemic infection, 
a period lasting from six weeks to three months. The secondary 
stage is characterized by general eruptions over the skin and 
mucous membranes, with evidence in general glandular enlarge- 
ment, nocturnal headaches and malaise, that the poison of the dis- 
ease is circulating throughout the whole body. This stage lasts 
for a variable length of time, but usually is complete in three 
years. The tertiary stage is marked by localized eruptions of an 
ulcerative character. 



1 82 COMMON DISEASES OF THE SKIN 

The secondary eruptions make their appearance within a few 
weeks after the initial lesion, and while the latter is still in evi- 
dence, and follow roughly a regular sequence. The earHest to 
show is a macular eruption of a very faint colour, usually most 
evident over the abdomen and lower parts of the thorax, but 
occasionally seen first on the lateral' aspects of the neck. The 
faint rose spots which constitute it are often not visible in a bright 
Hght but stand out prominently in a subdued light. As the 
disease progresses, the macules become more sharply defined 




Syphilis. Primary. Shows a hard chancre at the upper part of the left labium. 

and many of them change into slightly raised, blunt papules, 
some of which again within a few weeks become invested with a 
few white scales. As only a small portion of the original macules 
are concerned in this change, a mixed macular, papular, and 
papulo-squamous eruption is the one most often seen early in 
the disease. At this stage and throughout the whole of the 
secondary period the superficial lymph glands are found en- 
larged and mucous patches are seen in the mouth and about the 
genital mucous surfaces. The hair also begins to fall in a char- 
acteristic manner, small discrete bald patches forming which 



SYPHILIS 



183 



give the scalp the appearance of being spattered with tiny bald 
areas. Loss of hair may occur in this characteristic manner 
without the body showing any evidence of an eruption. Besides 
the forms of eruptions already mentioned, secondary syphilides 
may be vesicular, pustular, or squamous in character, or com- 
binations of these forms, some of which often closely imitate 
other skin diseases. One of the most constant characters of the 
secondary eruptions is pigmentation, usually developing when 




Syphilis. 



Secondary. Mucous patch on. the lower part of the left labium, which 
has been everted by the finger. 



the rash is fading out, but sometimes appearing with it, and now 
and then occurring alone. The staining is of a brownish or 
coppery colour and is equally well marked over the body, and not 
accentuated on the lower extremities as in other diseases in which 
pigmentation occurs. When it occurs without inflammatory 
reddening, it is commonly in the form of a cribriform network 
on the neck, forehead, or sides of the face. Another very no- 
ticeable feature in secondary syphihdes is their tendency to 
assume a circinate or gyrate outline, especially in the later mani- 
festations. The late secondaries, too, are less likely to have the 



i84 COMMON DISEASES OF THE SKIN 




Syphilis. Secondary. Early macular form, more pronounced here than is usual. 



SYPHILIS 



i8s 




Syphilis. Secondary. Early circinate eruption, common form. 



i86 COMMON DISEASES OF THE SKIN 




Syphilis. Secondary, showing maculo-papular eruption with tendency to grouping. 



SYPHILIS 



187 




Syphilis. Late secondary. Limpet-shell type of lesion, not very common. 



i88 



COMMON DISEASES OF THE SKIN 




SYPHILIS 




I90 COMMON DISEASES OF THE SKIN 

universal distribution of the earlier ones, but have a predilection 
for certain situations while still remaining roughly symmetrical. 
Thus the face is almost invariably involved, and the palms of 
the hands and soles of the feet, regions which escape in most 
other dermatoses, are quite commonly the seat of the disease. 

Throughout the whole of the secondary period, flat, wart-like 
papules having a moist secreting surface are seen around the anus, 
on the genitalia, and in situations where there is heat, moisture, 
and friction, such as the natural clefts of the body. These are 
known as moist condylomata and are pathognomonic of the 
disease. Whitish areas, more or less abraded and denuded of 
epithelium, looking like shallow ulcers and known as mucous 
patches, occur on the mucous membranes of the lips, mouth, and 
genitalia. 

Tertiary eruptions are not symmetrical in distribution, rarely 
cover more than a small portion of the body and are always 
ulcerative, producing cicatrices as healing occurs. The most 
common form is a nodular, creeping eruption, having a more or 
less wavy outline, spreading at the borders and healing in the 
central portion. The advancing edge is raised and nodular 
from the presence of small, irregularly shaped granulomata, 
which soon break down, leaving an ulcer crusted with dried 
purulent matter. x\s this ulcer heals the cicatrices which form 
may be either so thin as hardly to be distinguishable from the 
normal skin, or dense, thick, and irregular, depending on the 
depth to which the ulcer has extended. Tertiary lesions are 
always sluggish and chronic, and create little discomfort except 
what may be due to their accidental situation. On the covered 
parts of the body it is not unusual to find such a lesion that has 
existed for years and has caused so little inconvenience that it 
is discovered accidentally by the physician who has been con- 
sulted for some other ailment. Some regions seem to be spe- 
cially prone to tertiary lesions : these are the shoulders, forehead, 
over the lower ribs at the back, and in the neighbourhood of the 
larger joints. When the disease attacks the borders of the nose 
and upper lip there is less tendency to the formation of nodules 
and much deeper destruction of the underlying tissues, so that 



SYPHILIS 



191 




192 



COMMON DISEASES OF THE SKIN 




Syphilis. Tertiary lesions with dark brown pigment which persisted after cure of 

the disease. 



SYPHILIS 



193 




194 



COMMON DISEASES OF THE SKIN 



SYPHILIS 



195 




Syphilis. Early tertiary of the serpiginous type seen on the nose, cheek, and axilla. 



196 COMMON DISEASES OF THE SKIN 




Syphilis. Tertiary ulcerative lesion which suggested lupus erythematosu- 



SYPHILIS 



197 




Syphilis. Xodular tertiary ulcerating lesion. 



198 



COMMON DISEASES OF THE SKIN 




Syphilis. Tertiary. Gummata on the right leg, and ulcer formed by sloughing 
gumma on the left. 



SYPHILIS 199 

the whole of the alae nasi may be destroyed and the disfigure- 
ment be very great. Another form of tertiary lesion is pro- 
duced by the sloughing of the skin overlying a subcutaneous 
gumma or syphiHtic granuloma of the soft parts, which results 
in a deep, punched out, circular, or oval ulcer with undermined 
edges. After the gumma has broken down and the contents 




Syphilis. Tertiary. Gumma on the arm; the surface has just broken down. 

escaped, the ulcer so formed may spread at the periphery until 
large areas are involved. 

In Hereditary syphilis the disease is transmitted to the fetus, 
which suffers in proportion to the virulence of the parents' in- 
fection. The usual history in cases of untreated syphilis is one, 
at first, of repeated abortions, the product of each succeeding 
conception being carried by the mother a little longer, until a 



200 



COMMON DISEASES OF THE SKIN 



child is still-born at full term. In succeeding pregnancies, as 
the strength of the virus wanes, a child may be born alive with 
the secondary eruption fully developed and later others with less 
and less evidence of the disease, until finally a well-nourished, 
healthy looking child is born, and the eruption does not appear 
until weeks or months have passed. This, too, is the rule where 




Syphilis. Tertiary. Destructive ulceration of the nose. 



the parents have undergone partly successful antisyphilitic 
treatment, or where from the lapse of time the parental infection 
is of lower virulence, the disease making its appearance in the 
child sometime within the first six months of its life. In con- 
genital syphilis the eruption may present any of the forms met 
with in the acquired disease, but there are several common 



SYPHILIS 20I 

enough to deserve special mention. One of these is a bullous 
or pustular eruption consisting of large shallow, loosely-filled 
blebs, with cloudy or purulent contents, occurring most thickly 
about the head and extremities and noticeable by its involve- 
ment of the palms and soles. Another is a macular or maculo- 
papular eruption, somewhat darker in colour and more pro- 




Syphilis, Tertiary of nodular ulcerating type. 

nounced than the similar eruption in the adult, and showing 
moist papules about the anal region and buttocks. Owing to 
the liabiHty of infants to develop erythematous eruptions about 
the buttocks and genitals, syphilitic rashes are often first seen 
here, and are to be distinguished from the ordinary erythema 
due to irritating discharges by the presence of slightly raised, 



202 COMMON DISEASES OF THE SKIN 

moist, flat papules or shallow ulcerated surfaces, and by the 
absence of the general h3rperaemia. Ulcerative lesions in the 
form of cracks are common too about the angles of the mouth 
and nares. In the majority of children with syphilitic eruptions, 
the general condition gives one a clew to the nature of the rash. 
There is almost invariably snuffles and the child has a shrivelled 



^^■^_^j|rV^ 






^^M 




^^^^^^^^^^^H 


^J[y'.'>^' 




^ 


'x^.-.^^^^H 


■;;v^>'^ 




^^H • ' '^^ 




■^Lv^'i;^>^ 




^■'r^^'^slHk 








^^H ' >-.!>' < •^^^^l 


^^^^^H 


■ 


'■ 



Syphilis. Tertiary. Nodular tj^e. 

up and wrinkled appearance with the facies of a very old woman, 
the skin being dry, inelastic, and yellowish in hue. 

In the diagnosis of syphilis the Wassermann test of the blood 
is of the most importance ; as it, however, can only be carried 
out properly in a well-equipped laboratory, it is not always avail- 
able. The means of distinguishing between the Hunterian sore 
and other venereal ulcers is fully described in works on venereal 



SYPHILIS 



203 



disease and will not be discussed here. Most of these cases are 
seen by the dermatologist long after the initial lesion has dis- 
appeared, or where there has never been any recognized primary 
lesion, perhaps because it was extra-genital in situation. 

Secondary syphilis of the skin, as has been already pointed out, 
may simulate almost all of the common dermatoses. It is an ex- 




Syphilis. Early tertiary, serpiginous, nodular type. 



cellent plan to have in mind the possibility of syphilis in consider- 
ing the diagnosis of all eruptions which are not, hke herpes zoster 
or purpura, characterized by some prominent feature which 
labels them definitely. Points which should be given weight as 
indicative of s>"philis are, first, lack of uniformity in the lesions, 
An eruption which shows maculo-papular, papulo-vesicular. 
or papulo-pustular elements in an otherwise uniform macular 



204 COMMON DISEASES OF THE SKIN 

or papular type of lesion is suggestive. The distribution is 
often helpful, as the face and especially the forehead is almost 
always involved (the corona Veneris of the older writers), and 
the palms and soles are included in a general eruption much more 
frequently than in other diseases. The colour of many secondary 
lesions is of a deeper red with more brown in it than is seen in 




Syphilis. Hereditary. Girl of nineteen showing Hutchison's teeth. 

most inflammatory diseases, giving the raw beef appearance, or 
it may contain sufficient pigment to be of a coppery hue. If, 
along with one or more of these special features in the distri- 
bution or character of the eruption, the patient exhibits the 
general glandular enlargement, sore throat, mucous patches, or 
condylomata and nocturnal pains in the limbs and head, a 
positive diagnosis can be made. It is mostly in the later secon- 



SYPHILIS 205 

daries, when the severity of the constitutional symptoms has 
abated, that the eruption assumes the circinate or gyrate form 
which is so characteristic of the disease. 

Tertiary lesions of syphilis must be differentiated from the 
two forms of lupus, malignant disease of the skin, and blasto- 
mycetic dermatitis. The lesions produced by lupus erythema- 
tosus and tertiary syphilides often bear a very close resemblance 
to each other, the most striking difference being their rate of 
extension. Lupus, as compared with syphilis, is of extremely 
slow growth, ulcerates much less deeply, and is commonly con- 
lined to the head or face, showing but a single lesion of the bats- 
wing shape. Lupus vulgaris, being a disease of early life, is 
less likely to be confounded with syphilis, but the tertiary mani- 
festations of the congenital disease are not infrequently, however, 
because of their occurring as early as the fifteenth year, mistaken 
for it. In such cases the patient is usually unaware of the con- 
genital taint, and the early age precludes the idea of the acquired 
disease. In all doubtful cases where a Wassermann test cannot 
be obtained, a course of iodide of potash will settle the diagnosis, 
syphilitic lesions rapidly melting away under its influence. One 
point in connection with diagnosis should not be lost sight of ; 
namely, that tertiary lesions of all sorts may make their appear- 
ance after a long period of quiescence, as we have records of cases 
in which such lesions have cropped up twenty years or more 
after the last manifestations of the disease in the skin. 

In the diagnosis of hereditary syphiHs the family history plays 
an important part, recurring abortions or the birth of a dead 
child being strongly suggestive. In cases of known syphilitic 
parentage, if the child shows no evidence of the disease for six 
months following its birth, it may be considered to have escaped 
infection. Generalized or partial eruptions having the charac- 
ters described in the section on congenital syphilis should always 
be looked upon with suspicion, whether or not the parents present 
any evidence or history of disease, and a Wassermann test of 
the mother's blood should be taken. One evidence of hereditary 
syphilis which may occasionally prove of value is the occurrence 
of Hutchison's teeth. Here the permanent teeth, principally 



2o6 



COMMON DISEASES OF THE SKIN 




Syphilis. Hereditary. Papulo-vesicular eruption in child of two years who had had 
antisyphilitic treatment for a few months only after birth. 



SYPHILIS 207 

the upper incisors, are notched and somewhat peg-shaped, the 
ends of the teeth being slightly narrower than the portion in 
contact with the gums, but as it is only the permanent teeth 
that are affected this sign is of no value except in the tertiary 
lesions. 

In the treatment of syphilis three drugs are of unquestioned 
value, mercury, iodide of potash or soda, and arsenic. The first 
and second have been in use for many years, the last had fallen 
into disrepute but has of late been revived by new compounds 
and new methods of exhibition. Disappearance of the secon- 
dary eruption is most quickly effected by the intravenous use 
of arsenic in the form of salvarsan or one of its homologues 
combined with the administration of mercury. Diarsenol, which 
we have used for several years in place of the original salvarsan, 
has been found quite as effective and if anything less toxic. It is 
given doses of .3 to .6 gramme, according to the age and vigour 
of the patient, beginning with the smaller dose and increasing, 
if it is well borne. From three to six injections are required at 
intervals of from ten days to two weeks, a Wassermann test being 
made a month after the last dose. If this is negative, and clin- 
ically the eruption has disappeared, its use is discontinued for six 
months or so, when a second course is given. Mercury is given 
from the outset and kept up continuously for six months, and 
after that for twenty days out of each month, until the patient has 
been under its influence for two years. It may be used in many 
ways, but in our experience, grey powder (hydrargyrum cum 
creta) 3 to 6 grains daily has proved most satisfactory. In 
order to cope with its untoward effect in producing diarrhoea it 
is used in the form of Hutchison's pill, containing one grain of grey 
powder to one-fifth grain of Dover's powder (pulvis ipecacuanhas 
CO.). If the teeth are in good condition and kept so by frequent 
brushing, it can be taken for long periods without any unpleasant 
results. Mercury is also given by the mouth in the form of the 
proto-iodide or the bichloride along with potassium iodide, by 
inunctions, a method which is specially useful in children, and 
hypodermically, using the metallic mercury suspended in oil or 
one of several compounds in oil or water. All these methods 



2o8 



COMMON DISEASES OF THE SKIN 




Syphilis. Hereditary. Tertiarj', ulcerating lesions at age of nineteen, on the 
temple and below the mouth. This is the case from which the photo of Hutch- 
ison's teeth was taken after cure by salvarsan. 



TINEA VERSICOLOR 209 

have their advocates, and provided a sufficient amount is intro- 
duced into the system without causing any upset, it is of no 
moment how the result is obtained. Iodide of potash we have 
found of great service in the nodular tertiary eruptions, which it 
rapidly resolves if given in large enough doses. It should be 
given in 20 grain doses in a full tumbler of water, taken after 
food and in the majority of cases causes no ill effects, even when 
increased to 30 or more grains at a dose. The nodules rapidly 
melt away and cicatrization takes place, a complete cure often 
resulting in from two to three weeks' treatment. The iodides, 
however, do not prevent recurrence, and diarsenol and mer- 
cury require to be given as outlined above to prevent a return 
of the disease. In syphilitic infants, diarsenol may be given in 
doses proportionate to the age, by introducing it into the longi- 
tudinal sinus through the anterior fontanelle. It is better, per- 
haps, to keep the disease under control for the first six months 
by grey powder in ^ grain doses and inunctions of blue ointment 
(ungt. hydrargyri). Smearing the inside of the child's flannel 
binder with a mass of ointment the size of a large pea each morn- 
ing is a simple method of accomplishing the latter. If the 
mother is able to nurse the child she also should be on anti- 
s}philitic treatment. 

The local treatment depends upon the character of the lesion. 
The secondaries are better left alone, unless there is irritation, 
a rare event, when an antipruritic lotion can be prescribed. In 
the ulcerative lesions of the tertiary stage, the use of ungt. hy- 
drargyri ammoniatum locally is found of value. 

TINEA VERSICOLOR 

Tinea versicolor is a parasitic disease caused by a vegetable 
organism which invades only the superficial layers of the skin 
and causes no symptoms except brownish staining and sHght 
scaliness. The lesions formed by the fungus consist at first of 
discrete spots up to a dime in size, but as the disease extends 
the individual spots coalesce to form large stained areas, at the 
margin of which outlying small islands can always be distin- 



2I0f 



COMMON DISEASES OF THE SKIN 




TINEA VERSICOLOR 



211 




Tinea versicolor. Tj-pical eruption in the axilla. 



212 COMMON DISEASES OF THE SKIN 

guished. The shoulders and upper part of the thorax are the 
commonest sites for the disease but it may appear anywhere on 
the covered parts of the body. Prolonged exposure to sunhght 
apparently kills the fungus, as it does not extend above the 
borders of the collar or on to the forearms. The disease is a very 
common one among people who are not over-particular as to 
cleanliness, and as it occasions no discomfort and is for the most 
part invisible, is often allowed to exist for years. 

The diagnosis is readily determined by mounting scrapings 
from the brown patches in liquor potassii and examining them 
with a high power. The fungus, Microsporon furfur, is closely 
alHed to that of ringworm, showing mycelial threads matted to- 
gether and containing here and there groups of spores like bunches 
of grapes, this feature distinguishing it from ringworm where 
they occur in chains. 

Any mild antiseptic vigorously applied to the parts with a 
stiff nailbrush will destroy the fungus. A solution of hyposul- 
phite of soda, one drachm to the ounce of water, answers espe- 
cially well, as the solvent effect of the soda on the skin aids in its 
penetration. 

TUBERCULOSIS 

Invasion of the skin by the tubercle bacillus produces half a 
dozen chnical forms of disease, all except two of which are com- 
paratively rare. Scrofuloderma is a sluggish form of ulceration 
involving the skin and underlying tissues, and often arising in 
the small abscess formed by a suppurating lymph gland. The 
ulcer so formed is irregular in shape, of a dull red or purplish 
colour, and exhibits an undermined edge, as the skin is more 
resistant to the attacks of the bacillus than the soft tissues. 
Such an ulcer may also arise in situations where there are no 
glands, the primary lesion being then a nodule or tubercle in the 
skin. HeaHng occurs with the formation of thick, irregular 
cicatrices, which later give rise to considerable disfigurement, 
as they tend to retain their dark red or purplish colour for 
years and by contracting distort the surrounding tissues. The 
disease is met with mostly in children and young adults already 



TUBERCULOSIS 



213 




Tuberculosis. 



Scrofuloderma, showing ulceration following broken down lymph 
nodes. 



214 COMMON DISEASES OF THE SKIN 

the subject of some other form of tuberculosis, and the face and 
neck are most Hable to be affected, though any part of the body 
may participate. The age at which it occurs, coupled with the 
undermining character of the ulceration, serves to distinguish it 
from other similar affections. Treatment should be carried out 
on surgical principles, by removal of the diseased tissue and by 
encouraging the wound to heal with as little disfigurement as 
possible. 

Lupus vulgaris is a chronic, cellular growth of low vitality, 
tending to break down almost as soon as it appears, and charac- 
terized by small nodules or tubercles of a soft jelly-like consis- 
tence, pearly grey to bluish in colour, almost translucent, resem- 
bling boiled sago grains. These growths are so soft that a blunt- 
pointed probe can be pushed through them until it meets the 
resistance of the sound tissues underneath, and, as they break 
down, leave a pus-crusted ulcer ultimately resulting in thick, 
dense cicatrices. The disease begins in early life and may last 
for an indefinite period, becoming quiescent or healed in the 
centre and slowly extending at the border. While no part of 
the body is exempt, in the great majority of the. cases the face 
alone is involved, and when, as is commonly the case, it occurs 
in the neighbourhood of the eyes, nose, or mouth, the contraction 
of the scars or the deep ulceration causes marked deformity, 
the whole thickness of the walls of the nose being often destroyed. 
A single lesion is usually seen, but secondary ones may arise at 
some distance from the primary one. 

The points to be depended upon in diagnosis are the early 
age at which the disease makes its first appearance, the ulcera- 
tive character of the lesion, and the soft, friable nature of the 
new growth. Lupus erythematosus is often hard to differen- 
tiate from it, especially the hypertrophic form of that disease. 
Lupus vulgaris, however, is more destructive, and the nodules are 
softer and differ in colour, and the disease occurs in early rather 
than in middle life. An ulcerative tertiary syphilide is rarely 
single, extends very much more rapidly, tends to take a crescen- 
tic form and is uncommon in early life, except where the disease 
is hereditary, when other evidences of its nature will be present. 



TUBERCULOSIS 




Tuberculosis. Scrofuloderma. Two sluggish abscesses formed as seen here in 
child the subject of tuberculosis. 



2l6 



COMMON DISEASES OF THE SKIN 




Tuberculosis. Lupus vulgaris. 



TUBERCULOSIS 



217 




2i8 COMMON DISEASES OF THE SKIN 

Because of the tuberculous nature of the disease, treatment 
should be constitutional as well as local, and good nutritious 
food, an open air life, and everything that tends to increase the 
resistance of the patient are indicated. Locally, efforts should 
first be directed to reducing the inflammatory reaction and then 
to destroying the bacilli by means of strong escharotic or germi- 




Tuberculosis. Lupus vulgaris of the nostrils extending on to the mucous membrane. 

cidal applications. Liquid air, which answers so well in the 
erythematous lupus, has not proved very satisfactory in our 
hands. Repeated exposure to X-rays in many cases is found 
of service, but not invariably so, and it is impossible to tell before- 
hand whether it will be of benefit ; it should only be undertaken 
by an expert Roentgenologist. Removal of the active portion 
of the disease by curetting with a sharp spoon under surgical 



URTICARIA 219 

anaesthesia is an effective way of dealing with it, but this can 
rarely be done thoroughly enough to remove all foci of infec- 
tion at the first attempt, and has to be repeated as the nodules 
reappear. When hospital facilities are not within reach the 
repeated application of mild antiseptic ointments to destroy the 
pyogenic organisms, followed by escharotics, is the best form of 
treatment to undertake. Of the mild antiseptics, unguentum 
hydrargyri ammoniatum, unguentum hydrargyri oleatis diluted 
one half, or salicylic acid, 10 to 15 grains to the ounce, answer 
the purpose well. As destructive agents, one can use resorcin 
and beta naphthol paste (see Acne) , salicylic acid 60 to 90 grains 
to the ounce, pyrogallic acid one or two drachms to the ounce, 
or arsenious acid. The latter is a well-known remedy used in 
the form of Hebra's ointment, arsenious acid 20 grains, hydrar- 
gyri sulphidi rubrum one drachm, to the ounce of unguentum 
aquae rosae. Stelwagon suggests adding 5 to 10 grains of cocaine 
hydrochlorate to this in order to allay the pain caused by its 
use. 

URTICARIA 

Urticaria, or Hives, is the cutaneous manifestation of a general 
toxaemia, which may be due to various causes, but is most fre- 
quently gastro-intestinal in origin. The skin lesions consist of 
wheals, slightly raised, pinkish areas of regular or irregular shapes 
and sizes, few or many in number, fairly sharply defined, but 
showing a slight pinkish areola about the elevated portion. An 
identical lesion is produced by the bites of many insects, notably 
the mosquito. The wheals have no regular distribution, though 
the feet and hands usually escape, reach their full development 
in a few minutes, and after lasting for a variable time, commonly 
several hours, disappear rapidly without leaving any trace ex- 
cept in young children. In these latter each lesion leaves on 
fading a little, hard, intensely itchy papule, which is often seen 
surmounted by a blood crust, where the top has been removed 
by scratching. The disease gives rise to an intolerable itching 
or burning sensation, which often persists after the efflorescence 
has disappeared, especially in the papular type, and though each 



220 



COMMON DISEASES OF THE SKIN 



individual lesion does not last long, a sufferer from the disease is 
often never entirely free from irritation, as new wheals keep ap- 
pearing either continuously or in crops. Any slight local dis- 
turbance of the circulation of the skin, either by heat, cold, or 
ptessure, may result in a fresh outburst over the part affected. 
•In some individuals, otherwise showing a normal condition of 




Urticaria. Showing tlie distribution of the lesions 



their integument, the cutaneous vasomotor nervous system is so 
sensitive that slight pressure, such as that exerted by scratching, 
will give rise to wheals corresponding with the lines of pressure, 
and it is thus possible to draw figures on the skin with a blunt- 
pointed instrument and have them accurately reproduced by 
wheals within a few minutes. Such a condition has been called 
Dermographism or Urticaria factitia. 



URTICARIA 



221 




222 COMMON DISEASES OF THE SKIN 




Urticaria factitia. 



URTICARIA 223 

Urticaria is not difficult of diagnosis when the characteristic 
lesions are present or when one can get a history of their recent 
occurrence. It is in long-standing cases, where the scratching has 
led to secondary infection and the production of purulent sores, 
that confusion is apt to arise and the primary cause of the trouble 
to be overlooked. The disease may occur concomitantly with 
scabies, and the presence of a few wheals may lead one to over- 
look the presence of the more serious affection. Papular eczema 
produces great itching and somewhat the same picture as urtica- 
ria, but the papules are grouped and not scattered irregularly 
over the body as in the latter disease. 

Treatment is directed towards relief of the itching and removal 
of the underlying cause. Antipruritic agents are more easy of 
application in the form of lotions and should be prescribed in 
this way. Tar and its derivatives are most satisfactory as they 
are effective and not poisonous, our favorite being Uquor carbonis 
detergens, one or two drachms to the pint of water, sponged 
over the wheals as often as necessary. Carbolic acid has more 
lasting effects, but watery solutions are dangerous unless very 
carefully used. A ten per cent solution of menthol in olive oil 
reheves the itching but is objectionable on account of its soiling 
the clothing. Sponging with weak vinegar or soda solutions, or 
baths made with them, or even of plain water, will give tempo- 
rary rehef. Internally, treatment is to be directed towards re- 
moval of the cause, which in children is most frequently a gastro- 
intestinal toxin, due either to a faulty diet or a special idiosyn- 
crasy to some wholesome form of food. Sugar in excess, eggs, 
oatmeal, and certain fruits are all objects of suspicion. In our 
clinic the great increase in the number of cases during the season 
in which the small fruits are plentiful suggests them as the most 
frequent factor, and the strawberry is undoubtedly the most 
common offender in this respect. As a routine procedure one 
should empty the bowels by a saline purge. 



224 COMMON DISEASES OF THE SKIN 

VERRUCA 

Verruca or wart, the common variety of which becomes famihar 
to almost everyone in childhood, is a small tumour consisting of 
epidermal tissues well supplied by bloodvessels and, though 
nothing is known of the exciting cause, undoubtedly contagious, 
in the sense that one such growth may give rise to others. This 
form, Verruca vulgaris, is commonly sessile though occasionally 
pedunculated, is hard and horny in character, becomes grey or 
dark brown with age, when its surface often becomes irregular 
and broken up into segments. Children and young adults are 
the most frequent sufferers, a single lesion, the " mother wart " 
often appearing first, followed months later by many smaller ones 
either in the same region or on the uncovered parts of the body. 

Flat warts. Verruca plana, are common in children and the 
aged and seldom met with during the intervening years. In 
the old they appear on the face or hands as soft, slightly raised 
growths, irregular in shape, grey to black in colour, often rough 
on the surface and reach the size of a dime at times. Besides 
their disfiguring effect they are of moment from their hability 
to undergo malignant degeneration. In early life flat warts form' 
small, round or oval, very shghtly raised, smooth growths from 
a pinhead to a lead pencil in diameter, usually present in large 
numbers on the face, arms, or hands. Often when small they 
are almost invisible, but as they increase in size the colour, origi- 
nally slightly deeper than the normal skin, becomes darker. 

Pointed warts. Verruca filiformis, thread-like in shape, are 
occasionally seen upon the face, and venereal warts, Verruca 
acuminata, soft cauliflower-like growths, often reaching an 
inch or more in length, are seen about the mucous membrane 
and skin of the genitals, especially in women suft'ering from an 
irritating discharge. 

While many dermatologists express faith in the internal treat- 
ment of warts, their well-known spontaneous disappearance at 
times renders one sceptical of reported results from arsenic in 
small doses, or daily purgation with Epsom salts, the favourite 
remedies. Locally the common variety can be removed by 



VERRUCA 



tm 



Verruca. Small filiform type. 



226 



COMMON DISEASES OF THE SKIN 




VITILIGO 



227 




228 



COMMON DISEASES OF THE SKIN 



excision, caustics, electrolysis, or freezing. Freezing by means of 
liquid air or carbon dioxide snow we have found most satisfactory 
in the treatment both of senile warts and the commoner forms, 
but when these agents are not obtainable, the common form 
can be removed by daily apphcations of acid nitrate of mercury, 
which produces a small abscess about the base of the wart, ena- 
bling one to pick it out entire. For the fiat forms seen in early 
life an ointment containing from lo to 30 grains of salicylic acid 
to the ounce is often of value. 

VITILIGO 

Vitiligo, the opposite condition to chloasma, is a loss of all 
pigment in the skin, rendering the part white. The disease is 




Vitiligo. Showi the increased pigmentation in the neighbourhood of the patches. 



generally seen first about the backs of the hands and face in 
the form of small oval or round spots of milky whiteness with 
accentuation of the normal amount of pigment at their margins. 
The spots slowly increase in size and become irregular in shape, 
but the general distribution remains roughly symmetrical. Apart 



VITILIGO 229 

from the loss of pigment no change occurs in the skin of the 
affected parts. 

In persons with a very pale skin the contrast between the 
white patches and the surrounding pigmented areas may lead to 
a mistaken diagnosis of chloasma, especially during the summer, 
when the normal pigment is increased. There is no form of 
treatment of any value. If it is desired to remove temporarily 
the disfigurement caused by the disease, one may try carefully 
painting the white patches with a stain made of a one per cent 
solution of chrysarobin in alcohol, until the desired colour is 
reached. 



Printed in the United States of America. 




' .l.t ' i. II 



i)y 



